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 Byrne - Cleveland Clinic Foundation

 

Patrick Byrne, MD, MBA

Chief, Integrated Surgical Institute,

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

Cleveland Clinic Foundation

Immediate Past President, Academy of Facial Plastic and Reconstructive Surgery

 

                Dr. Patrick Byrne is Chief of Cleveland Clinic’s Integrated Surgical Institute (ISI) and Chair of the Department of Otolaryngology–Head and Neck Surgery. In his role as ISI Chief, he leads five surgical departments (Otolaryngology–Head and Neck Surgery, Orthopaedic Surgery, Urology, Ophthalmology, and Plastic Surgery) as well as two multidisciplinary centers (Endocrine Surgery and Breast Surgery), across Cleveland Clinic’s global footprint in Ohio, Florida, London, and Abu Dhabi.

Prior to joining Cleveland Clinic, Dr. Byrne spent nearly two decades at The Johns Hopkins Hospital, where he served as Director of the Division of Facial Plastic and Reconstructive Surgery and held professorships in Otolaryngology–Head and Neck Surgery, Dermatology, and Biomedical Engineering. He co-directed the Johns Hopkins Face Transplant Team and led major institutional initiatives, including the development of a large multidisciplinary ambulatory surgery center.

An internationally recognized facial plastic and reconstructive surgeon, Dr. Byrne specializes in complex facial reconstruction, facial reanimation, and aesthetic surgery, with particular expertise in rhinoplasty. He is widely known for his pioneering work in the treatment of facial paralysis in both adults and children. His clinical and translational research has resulted in more than 100 peer-reviewed publications, as well as innovations in biomaterials and surgical device development.

Dr. Byrne remains actively engaged in clinical and academic endeavors, including co-directing the Randolph Capone Cleft Lip and Palate Team at GBMC. He has founded several healthcare startups and holds an MBA from The Wharton School.

He has led numerous global humanitarian initiatives, establishing multidisciplinary cleft care programs and performing reconstructive surgery in underserved regions worldwide. He currently serves as Immediate Past President of the American Academy of Facial Plastic and Reconstructive Surgery.

 

JT: What do you love the most, and what do you dislike the most about facial plastic surgery?

PB: Oh, man, you just dive right in. Love the most.. I love the impact we can have on patients. I love how personal it is. I love how the bar is very high for technical precision. The way I often share that with trainees who are wondering what to do, or patients who are curious is this: I don't know that there's another field in which the degree to which the patient and all their loved ones render judgment on your surgical skills is so powerful. For essentially every other surgical specialty, what happens in the OR is a black box. It's inside the body, or it's covered by clothing, or, you know, it just isn't something that people can evaluate. But in facial plastic surgery, a high percentage of what we do is not only on display for the patient, and the world, and the loved ones to evaluate, but it's usually on display on the one area of the body that is scrutinized the most by far for its appearance: the face. I feel like there's something unique about that that attracts certain personality types, and certainly I like being in that crucible, I suppose.

What do I dislike? There are certainly challenging conditions and patients we deal with. I think… the… level of decision-making and psychological complexity is one of the things that makes it very interesting to me over the years. But it is also a bit grueling. So, I wouldn't say I dislike it so much, but in comparison to some other fields in which there's a pretty discrete set of options. And there's a relatively agreed-upon, correct treatment plan. That's often not remotely the case for this subspecialty, in which there is enormous nuance in judgment. What we're trying to really do, in most cases, is to produce a change in the psychological state of the patient, that they perceive and experience as valuable and worth going through the cost of surgery. I mean, all the elements of surgery, including healing and swelling, all that. And you know, that makes it to me, a more nuanced and complex decision-making process than maybe some other specialties I could have chosen to focus on.

JT: That's a very, very interesting thought process. I never thought about it like that. Thank you for sharing that.

PB: Yeah, another way to put a pin on that is this: Often in clinic, if there's a resident with me, and certainly fellows early in the year, I'll draw on a little piece of paper two circles, like a Venn diagram, and then see overlap in the middle. And in one circle are patients who have a physical ailment, or deformity or dysfunction that you feel confident that you can improve with a surgical procedure. And then in the other circle of the Venn diagram is patients who have the mental ability to experience the psychological benefits of any surgical procedure. And I try to limit all my surgery only to the groups that have both. And it sounds simple, but… it often isn't. Even in some cases, such as functional nasal surgery, where it's not always easy to actually land on the patients who are in the middle of that Venn diagram, we're constantly taking that into account. How does this patient perceive this problem that they're dealing with? And, are they capable of feeling better after it? Now, that's obviously for all the elective stuff. A lot of what we do is elective.

Reconstructing a jaw after a mandibulectomy or skin cancer, or trauma- that group of patients has similar dynamic, because they we all care about what we look like. But the decision-making is far more simple. And that's, a nice half of the field. The aspects of reconstructive surgery where it's fairly straightforward, and patients really need to be treated. The highly elective aspects is where a lot of judgment and nuance comes in and gets more psychologically complex.

JT: I see. Thank you so much. Clearly you've built a very impressive career across surgery, leadership, and innovation at the highest level. What drives you on a day-to-day basis, and how has that changed over time?

PB: What year are you?

JT: I'm a second year.

PB: Oh yeah, that's cool. I remember, like, yesterday being a second-year resident, I'll tell you that, and I think at that stage, I really wanted to be challenged, I wanted to do complicated surgery, I wanted to do difficult surgery, I wanted to do big cases. And so at that stage in my career, I was very, crystal clear in my mind that there were certain areas of otolaryngology-head and neck surgery that I would hate, and I just would never do it. And in my mind, you know, I really liked the stuff that seemed big and difficult, so I was immediately drawn to head and neck cancer, and then quickly pivoted to the reconstructive aspect of head and neck cancer, including free tissue transfer. That was my first love. I just want to do things that are difficult and challenging, and get really good at it, and make an impact.

Overtime, what I realized I really like building things and solving complicated problems. I think it's fun to try to find a solution for a complicated nasal defect, but it's also fun to try to solve for a program that's maybe not doing really well, and may not have a lot of enthusiasm, or maybe not particularly productive, either academically or clinically. And how do you rally a group of people to think more in terms of a growth mindset, that “we can do this”, and “here's how we can do it”, “let's figure it out together”. So that idea of building cool things became really, really fun for me, building new programs that didn't exist before. Our new fellowship program, our new cleft lip, and palate program, our aesthetic program, our microvascular program, our research program, and so on. It’s just a fun thing to do, because you're trying to make an impact that lasts beyond what we can do as individuals. In the last few years that's what drove me. By the way. I never, never aspired to any particular position. In a million years, I never thought I'd be a chair, much less than a chief of an institute. But I like building cool things.

In terms of the self-identity, I just shared with somebody the other day, I think it's been helpful for me, so, maybe you or your readers can ponder this: during the first half of my career I had an intense desire to become a great surgeon or a great leader. I really wanted to be great. So I was always very self-critical about my surgical Procedures, and my ability, and the outcomes. But that evolved over time a little bit. It's a subtle nuance, but it's been helpful to being someone who is always trying to learn and get better. So, conceiving of myself, either in terms of leadership, or clinical abilities, or as a father, or whatever it is, I'm the type of person that is always gonna try to get better and learn something every day. I think it's more helpful than aspiring to be great, because we all have times where we fall short. And if we adopt the mindset of a constant learner who's always growing. we manage that, and we learn from it a little more efficiently, I think, and move on to becoming better quickly, instead of, indexing on our shortcomings as much, if that makes sense.

JT: It does, and to me, it sounds more like a stepwise or more mature, if you will, approach to becoming great. It probably accomplishes the same goal, but through a different, more realistic approach, maybe. Or at least that's my interpretation.

PB: Yeah, maybe…I think you're right; it may be a little more focused on process and less on outcome. It's the process of growing and getting better and putting in the work that we should drive our satisfaction from probably more than the outcome of that effort.

JT: And it's really impressive how this approach transcends into the different aspects of your professional life. You mentioned building cool things, I'm presuming the operating room, and then in a department, the Cleveland Clinic health system and the whole institution.

PB: Totally, it was making a nose from scratch, and then that blends into building a division at Johns Hopkins that we could be proud of, and building a fellowship program, building the department at Cleveland Clinic that we can be proud of, and now we're working on creating this sort of surgical specialties institute across the globe, and it’s really exciting to build something special.

JT: For sure. And speaking of Johns Hopkins, I was in our resident clinic this past Wednesday, with another alumnus from Johns Hopkins, Dr. David Kennedy. He mentioned the Hale^© device, and he brought it to my attention, so I really wanted to ask you about that. How did you develop an interest in medical devices? Having discussed with you for a few minutes, I’ve already realized that you love building cool things, but I would love to hear a little bit more about that, if you're eager to share.

PB: Well, first, what an honor that David Kennedy even knows about Hale^©. That makes me feel great. You just made my day, so thanks for that!

JT: He had very specific comments about it - because I initially visited its Amazon website, and he was like “no, you have to go to the Hale^© website, this is where it says that Dr Byrne was the one that created this”!

PB: Well, that was simply, years and years and years of taking care of patients with nasal valve obstruction. The Breathe Right strips helps a lot of people, but my intuition all those years, was that it seemed like for about a third of patients it works great and they use it, but probably two-thirds of patients with nasal valve collapse who tried the Breathe Right strips say “yeah, it doesn't really work for me”, or “I don't like it”, or “it doesn't stick to my skin”, or whatever it is. So, for years, I was wondering if we can design something that pushes from the inside, like a modified Cottle maneuver, instead of pulling from the outside, and I thought it would probably work better.

When I started working on it was when I was in the executive MBA program in Philadelphia, about 10, 12 years ago. And it really helped me to organize an approach, and then worked with engineers at Johns Hopkins to develop a product. By that time, there were other entrants on the market. There are actually quite a few stents now. I think ours is the most scientifically based and anatomic of any, and it definitely works. Entrepreneurship is not for the faint of heart. I'm motivated, again, to build something new that will outlast me and helps people. I think in anything we do, like, there's nothing better than that. Let's put our efforts into something that will help people, even when I'm underground. You know, that would be a nice legacy to leave.

It’s a long story in terms of the evolution of the company and all the ups and downs with that, because it is tricky, but I tried to shepherd that alongside all of my other duties. And there's pros and cons of that. Mostly cons of trying to do too much at once, but I think, it's out there, and we're helping some people, so I'm pretty proud about that.

JT: Thank you. Thanks for sharing this story. Now, going back to something that you said earlier, you said that initially you wanted to do big surgeries, and you had initially an interest in head and neck cancer, and then pivoted to the reconstructive aspect of it. So, what would you advise someone with a background on an adjacent yet different field? Like head and neck cancer. Do you personally perceive that as a barrier or, as a benefit, for a career in facial plastic surgery?

PB: Oh, no, I think it's not uncommon for people with an interest in head and neck cancer treatment to ultimately focus more and more on reconstruction. A little less common, like in my case, where I kept evolving and even built a very busy aesthetic practice, you know, and there's reasons why I pursued that. But, no, I think it's a wonderful background for all kinds of reasons. I think it's a good fit. And, you know, if there's one thing that I really feel strongly about, it's that when a resident, a med student resident starts down a certain pathway, they really should feel free if you feel confident that they're on the wrong pathway, they should feel free to pivot.

I just had a wonderful conversation a few weeks ago with a former resident at Hopkins in Otolaryngology Head and Neck surgery, who now works for a big consulting firm. And, he realized halfway through residency that, you know, this isn't really what I want to do. And he's really happy, and he's applying his knowledge, both of medicine, but also those years as a surgeon, to support his firm, clients, and I think that's wonderful. So I think it's a good fit, but I also think no one should feel stuck on a certain pathway in life.

JT: Thank you. That's, that's really insightful. I don't know if you have time for one more question.

PB: Yep. Let's try to make it through your list, if we can.

JT: Thank you. So I want to move to research, which, I know is, is another interest of yours, probably, given how productive you've been. Historically, FPRS compared for example to head and neck, is lagging a little bit in high-quality, basic, and translational research. I don't know if you think that this is a first statement, but I'm curious to see what you think -do you see that changing? And if you do, where do you think the real breakthroughs will come from in the coming years?

PB: I don't think it's an unfair statement at all. If you just look at NIH funding, then you know that head and neck cancer and audiology/otology, if you were to combine them, tend to get tend to receive a predominant share of the funding. And that's a reflection not only of the priorities of our federal research infrastructure, but also reflects, to some degree the amount of interest and activity bubbling up from these fields. So, it's hard to know which is more impactful, but certainly Facial Plastics has less translational and basic science, in a traditional sense.

Despite that, in the public sphere, there’s an enormous amount of investment, right? And that's because of the multi-billion-dollar aesthetics industry. So, in terms of energy devices and biologics and topical agents etc., there's a lot of interest there, for sure. I am intent on contributing to, as best I can, to the advancement of science within facial plastic and reconstructive surgery. And the way I view the field is that there are 7 or 8 key domains within facial plastics, and I always try to keep all of them in mind when we're talking about sustained effort to build the program. That could be a training program for residents, it could be a fellowship program, it could be a research program. And those areas are: head and neck reconstruction, including free tissue transfer, skin cancer management, including Mohs reconstruction, rhinoplasty, including revision, aging face and all the stuff that comes with that, surgical and non-surgical, congenital deformities including cleft lip and palate, facial paralysis and reanimation, trauma, and probably should also include gender affirmation work, because it has some unique aspects, although it combines the technical aspects of the rest. So, 7 or 8, depending on how you want to categorize it. And so, in the fellowship programs I've been part of, and the program building I've been part of, in my own learning and skills acquisition over my early years, I think it's important to keep those different domains in mind, because they have quite obviously much different foci in terms of any research investigation, any questions you're going to ask.

 As you know, there's a lot of work being done in reconstructive surgery. With biomaterials and advanced patient-specific planning. This is all advancing pretty rapidly with AI. In facial paralysis, there's very interesting work being done for many decades now in nerve regeneration. Hasn't translated yet into any big breakthroughs. We've made incremental technical improvements that have transformed the field. But we haven't solved yet for an artificial muscle, for example, to close the eyes and blink. Or an artificial sphincter around the mouth for oral competence. I think that's on the horizon, those sorts of things. We certainly hope so.

And then, you know, you go down the list, and each one of these domains has an opportunity for us to have better solutions. So, the optimist in me is that we can keep developing programs that emphasize real research in the academic sphere and across all 7 or 8 domains of facial plastic surgery. But that's tricky, because if for example, you're a head and neck cancer surgeon there's a whole infrastructure in place. So, you are going to get your best opportunities in an academic location. And then with that come all the resources and advantages of a research infrastructure, including translational research. Whereas in facial plastics, depending on your interest, people often tend to bifurcate into aesthetics and reconstructive. I've never been one of those people, I've always done both, and I think it works for me. But because of that bifurcation, many people go to private practice, and even if they do want to do both, it's just hard to do both, because then you don't have the support of the whole infrastructure that you need, for example, to do free flaps. So you're siphoning much of the talent out of academia and into this private sphere, just based on the practicalities of practice support. Where people do get involved, they work with private companies on device development. There's a lot of activity in our academy with that. But I think that explains why, in general, though, there's a more sizable corpus of research activity and people pursuing it in some of the other fields than facial plastics.

As I said, though, I'm really hopeful that places like Hopkins, Cleveland Clinic, several others, UC San Francisco and Oregon, Michigan, Minnesota and others -I won't keep going, because I'll leave some of my friends out somewhere- but there's a lot of good places doing a lot of good facial plastic research, and I think we need to keep pushing that.

JT: Thank you. This is really encouraging, especially when coming from someone like you.  No on to my next question: like you said, you've built many different programs on many different levels, so I'm sure you've hired a lot on all different levels. I'm just curious what traits you're looking for, and what is an immediate red flag for you.

PB: Your questions are gonna make my next appointment run late, because these are good questions, that I do think about a lot. Here's something interesting for your readership to ponder. There are certain personality traits that tend to correlate with a lot of success as a medical student, a resident, a fellow, and a faculty member if someone decides to go into, academics, or practitioner in private practice. These include drive, ambition, discipline, high character, and honest self-assessment in order to strive to continually improve. And those characteristics often lead to very successful practices, including academic practices. I have some private ventures, as you know, but I'll speak from the perspective of an academic, a clinician here and later. Those traits aren't often helpful as a leader, though. And in fact, sometimes there's a famous book by a guy named Marshall Goldsmith, and the title sort of tells you where I'm going. It's called “What Got You Here Won't Get You There”. When you're trying to construct a team, for very practical reasons, you value teamwork, selflessness, ability to be collegial and work with others, put some shared goal above personal interest. You know, these are the things that highly functioning top teams do. And sometimes, the traits that make superstar individuals don't always mesh well with the team.

So, when we're recruiting, what I try to find are those special people who have the drive, and the ambition, and the uncompromising commitment to excellence that makes these great innovators within surgery, and these great, huge practices. Because you develop a reputation for being special, and people are drawn to that. But you also need to have the self-awareness and system-level thinking to understand the importance of the big picture, and how you integrate and support that.

These people are out there, but it's harder it's harder to find than one might think, and I think that's one of the things I learned as a chair that I didn't have insight into when I was grinding away as a faculty member all those years in Baltimore. So, I look for excellence. I stole this from someone else, but humble, hungry, and smart is a good trifecta for people to have. The smart part implies talent. It's better to have someone with more talent than less. But if they're not hungry to contribute and grow and if they're not humble and aware of themselves and each of our own dependence on each other for success, then I think you're missing something in the sauce.

JT: I'm truly amazed that you said that. Several years ago, maybe 5 years ago, I had someone in the blog from Cleveland -I'll tell you who- who gave me a very similar answer. He used the exact same three words, and it got stuck with me. I actually ended up writing that on a piece of paper and even carried it with me when I moved. I had it on my wall when I was doing my postdoc for 2 years and then when I was interviewing for residency and it kept me motivated. That was Dr Ted Teknos from Case Western and the Seidman Cancer Center, across the street from you!

PB: Oh, cool, I'll have to tell Ted, that's a really great… he's an amazing guy, that's awesome! When work out in the morning sometimes I listen to podcasts, and this morning I was listening to Admiral McRaven's book on leadership. It just came up on my Audible, and he gave a similar story that emphasized the humble part. He thought he was going to get some sort of big promotion. He was called in as a young ensign, and it turns out that his superlative performance in his first year in the Navy was being rewarded by making him construct a float for a parade. And he was so offended at first, but then he learned a lesson that even the smallest task you want to take with humility and do your best job, and that people who can adopt that and set aside their ego, they tend to be more successful over the long term, and often get rewarded with bigger opportunities.

JT: And I think that's a very helpful lesson that translates to our experiences as residents, because we oftentimes face those tasks, and it can be very tricky if you underestimate them, or you don't put your whole self and your whole heart into them.

PB: Yeah, I mean, it can feel as if sometimes trainees, understandably, feel like they're taken for granted, right? And asked to do a bunch of scut work and that's not appropriate. There is a balance, of course, because you have to stand up for yourself, even as a trainee, to be respected. But you don't want to indulge - none of us want to indulge- the entitled side of our personalities either, right? Because it just doesn't help. It just doesn't help.

JT: For sure, and it doesn't help you grow. Dr. Byrne, here’s my last question for you: What would you like to be remembered for? What would you like your legacy to be?

PB: Well, I hope we build cool things that last well beyond me, so if, there's discrete accomplishments, I guess, that I would love to see happen, they're probably subordinate to the type of person I hope I'm remembered as. But on the discrete accomplishment side, my family's the most important. Really, the only opinions that truly matter are about 7 people on this planet who I actually care what they think.

My four kids, my wife, my 3 siblings, and maybe some of my closest friends. And I say that not just jokingly, because I think it's helpful not to be too concerned about what people think of you. That is one thing that a very good friend of mine, who actually has a prominent role now, nationally, said: I don't think I could be a chair because, you know, I want to be liked too much, and I don't know if I could make those tough decisions. Do you have kids?

JT: I don't.

PB: Now, you're young, but someday you may. And even with your own kids. You, you have to make decisions that they don't like because you love them. And you know that when you make those decisions out of complete selfless love for your child, some of them, they're gonna dislike you for it. But that's your job. Right? There are kids running around in our clinic who are 4, 5, 7 years old, clearly addicted to an iPad. And that's the narcotic that their parents use to keep them in line. And they'll say, “well, gosh, but it's so hard, you know, I've got 2 or 3 other kids, and otherwise he's screaming all the time”. And my thought is, well, that's your job. Your job is to protect your child, and if they hate it, that's what you have to do. And I feel very strongly about this, because that translates into professional relationships, and as a leader. If you really care about everybody in the organization that you're responsible for, you need to prove it, and that includes not infrequently making decisions that at least some people aren't gonna like. But if you care about them, and you care about the organization, you just have to do it. So I'm prefacing, what I hope people will remember about me. I hope that I'm seen as fair and always indexed on the shared vision. I certainly strive for that. That we're gonna try to accomplish something meaningful that makes the world a better place. If there's one thing that I try to rally my life around, it's that I'm trying to live a life in which I accomplish meaningful things, do meaningful work that makes the world better, for someone. So that's probably as much as anything. I hope the Division at Johns Hopkins and the Cleft Lip and Palate team I helped create in Baltimore, and the Department that I've led, and the Institute that I've led, and the companies I've started, hope they all do well and make the world a better place long after I'm dead. That'd be nice. But, you know, there's some luck involved there, too, so at least I gotta be a good person along the way. I fail at that every day, for sure. But hopefully we all are just trying to get better.

JT: That was an extremely inspiring discussion. Thank you so much for sharing these thoughts. It was incredible. I'm truly amazed, and I really appreciate your time. I know we went way over time, and I appreciate you doing that.

PB: That's alright! Appreciate it very much, Jason, I love what you're doing. Keep being creative and following your own path. I think it's awesome!

JT: Thank you so much Dr Byrne, really appreciate it!

Dr Deschler - Harvard Medical School/ Massachusetts Eye and Ear Infirmary

 

    Daniel G. Deschler, MD, FACS

Professor and Vice-Chair for Academic Affairs,

Department of Otolaryngology- Head and Neck Surgery,

Massachusetts Eye and Ear Infirmary,

Harvard Medical School

 

Daniel G. Deschler, MD, FACS is the Vice-Chair for Academic Affairs for the Department. of Otolaryngology-Head and Neck Surgery at the Massachusetts Eye and Ear Infirmary. For a decade, he served as the Director of the Division of Head and Neck Surgery in the Department of Otolaryngology-Head and Neck Surgery at the Massachusetts Eye and Ear Infirmary (MEEI), as well as Director of Head and Neck Oncologic Surgery at the Massachusetts General Hospital. He currently co-directs the Michael Dingman Fellowship in Head and Neck/Microvascular surgery which he founded in 2006. He was Secretary/ Treasurer and President of the Society for University Otolaryngologists and President of the New England Otolaryngology Society. He also served on the Executive Council of the AHNS as the Chair of the Patient Care Service and served as Program Chair for the AHNS 11^th International Conference on Head and Neck Cancer in Montreal.

Dr. Deschler received his BA at Creighton University and received an Honors degree in Medicine from Harvard Medical School. After concluding his Otolaryngology-Head and Neck Surgery residency at the University of California, San Francisco, he then completed an advanced fellowship in head and neck surgical oncology and microvascular reconstruction with Richard Hayden, MD in 1996. Dr. Deschler joined the Staff of the Massachusetts Eye and Ear Infirmary in 2000 and is currently a Professor of Otolaryngology-Head and Neck Surgery at Harvard Medical School and he is honored to be the Inaugural Dr. Eugene N. and Barbara L. Myers Chair in Head and Neck Surgery at the Mass Eye and Ear. He and his wife, Eileen Reynolds, MD are the Faculty Deans for Leverett House at Harvard University.

He has authored over 240 peer-reviewed publications, as well as numerous books, book chapters and education reviews. He serves on the editorial boards of the Annals of Otology, Rhinology and Laryngology, Head & Neck. Laryngoscope and UpToDate. He has served as the Otolaryngology Section Editor for UpToDate since 2002 and chairs the Thesis Committee of.

Triological Society. Dr. Deschler's clinical interests cover the breadth of head and neck oncologic and reconstructive surgery including advanced malignancies of the upper aerodigestive tract, salivary gland diseases, microvascular reconstruction and general head and neck reconstruction. His research interests overlap the breadth of these areas including speech following pharyngeal/Laryngeal surgery and reconstruction as well as management issues in the treatment of advanced head and neck malignancies

 

Jason Tasoulas: Dr Deschler, I recently read a bit about your story and was truly fascinated. I understand you grew up in rural Illinois before becoming one of the world’s most accomplished surgeons. I would love to hear more about your journey, if you’d be willing to share some of it.

 

Daniel Deschler: I grew up in a small town in Illinois. Neither of my parents went to college. My dad left home when he was 17 and joined the army. My mom grew up in post-World War 2 Germany. She actually met my dad when he was in the service, and they moved to the States when my mom was 20 and I was born shortly after. I have a brother who's 8 years younger than me, and I had a really wonderful family. My parents really valued education and what it could do for you.

So then I went to a Catholic High School and then I went to a Jesuit University in Omaha, Nebraska, and I really made some great friends there, and it allowed me a lot of time to grow as a person and explore whether I could do medicine and whether I might like it.   And I really had a great 4 years there, and part of that time I  went away, and spent 6 months studying in Vienna, at a time when people rarely  studied abroad.

 

Jason Tasoulas: And you studied theater, if I'm not mistaken?

 

Daniel Deschler: I did!  I was lucky that I did well in the sciences, and so that then gave me a lot of freedom about what I could do in college. So I was a history major and I did a part of that while I was studying in Vienna. I did a lot of theater but, because it wass a Jesuit university and has professional schools, including a medical school, if I wanted to take anatomy I went over to the Nursing School, and I took human anatomy rather than having to be in the biology department and do cat anatomy. And then, when I did Physiology, I did it through the Pharmacy School. I did Biochem through the graduate school. So it really gave me this great opportunity to get everything I needed done to graduate, but also take advantage of all the stuff that you can do at a really nice university. And like I said I made some great friends.

My family was supportive, and on a whim, I applied to Harvard Medical School. I got in, and that's what really changed things for me. Because when I came to Boston, all I wanted to do was go to medical school to be a doctor and take care of people, and I thought that that was cool.I was thinking that that was just going to be good enough for me. And then I saw what people were doing with medicine while doing that, and the way that they looked at questions and asked questions about everything. And it just forever changed the way I looked at this wonderful trade, medicine!

It let me evolve in a way that I get to do both. I get to be someone's doctor and be an important part of their life and let them be part of my life. And then yet I also get to teach, and answer these questions, and advance the field and learn all the time. So that was really a seminal thing for me.

I also  met my wife in the 1st week of medical school, and we dated all through medical school, and we were engaged just before the match. I met my best friend and my life partner! So you really can't ask for more from the medical school than that- I don't think it was designed to be a dating service, but it worked out for me! That's my pathway. And I've always just been really fortunate to have good friends, have the supports, but also, push things and enjoy things.

 

Jason Tasoulas: That's incredible. I'm impressed by the fact that several things that I was hoping to touch upon during this interview you've already mentioned here! It’s very fascinating to learn about your journey. To get there I'm sure that required a lot of perseverance and persistence, and a lot of effort. So, I'm curious to understand what kept you motivated during this journey.

 

Daniel Deschler:  I think that I never really lacked motivation, because, there were always people around me who were doing it better, and doing more of it than I was at that time, and so they provided roadmaps of what the pathway would be if I chose to engage in that. And it's not that everybody needs to engage at one level- the ultimate level. If you wish to, then you're volitional about that. And it means that, for one thing, you need to practice. You just don't learn to tie well by only tying in the OR on the days you operate. You tie a thousand knots, so that when you're asked to tie one perfectly, you can. and that knot matters to that person at that time. And so, you watch your chief residents or senior residents who really are doing it well. And you're like, “What is it that they're doing that I want to do?”, and then you watch the ones that aren't doing it so well, and you say “Hey, how do I make sure that I don't fall into that trap” and “How do I do it better than that?”. Not that they're bad, but I want to do it better than that. What are the things to do? And then you expose yourself to great people out there, and let them teach you, and learn from them. “Steal” little things from them. If you watch one talk and you remember something in an operation 5 years later, it can let you make a difference in someone's life - what a great moment that is.

So I never really lacked motivation in it. And I still think that I'm getting better at things. You know I've probably done well over 2,000 parotidectomies, and I still feel like I'm getting better at it. I still feel like I'm doing things that I couldn't have done 5 years prior. That's really an exciting part of life.

 

Jason Tasoulas: I remember when you published on your first 1000 parotids, several years back. That was already an impressive number. It's now double! So that's even more impressive, obviously!

 

Daniel Deschler: Well, the thing about that paper is not that one guy did a lot of parotids. The thing about that paper, the reason I wanted it out is that it controlled a major variable. You had one person who does it the same way with the same set of standards. So if you apply that methodology and that standard, then you can glean meaningful data from that. You take out a key variable of different practitioners, different times, and different things like that. So you know that paper to me said that you can do these operations with residents and trainees, and you don't have to be slow, and you don't have to sacrifice quality because every one of those operations was done with a fellow or a resident. That's what that paper is about to me. That's where this part of life is fun, because you can start to apply all the things you've learned over time.

 

Jason Tasoulas: Dr. Deschler, what distinguishes a good from a great surgeon? What makes a great surgeon for you?

 

Daniel Deschler: I think that a great surgeon is someone who knows when to operate and when not to operate and then knows how to operate and how not to operate. Someone who is always motivated by the central core tenet ofsurgery, which is to benefit a person in a time of need. And , if you have people like that, then by the sheer force of that mission, they acquire the technical skill to do that. Or if they don't specifically have it, they surround themselves with people who can do that. And I think that that's what really makes a great surgeon.

Technically, in my career, I probably operated with, maybe 5 people that I thought were outstanding technical surgeons. Two of them were in general surgery when I was an intern, and then the others were in otolaryngology. They were exceedingly skilled, technically, which was great to watch.  I greatly revered them, because of their ability to know when and when not to operate. Not only how to take a patient through a procedure technically, but also take them through it before and after because I think that's just as important.

 

Jason Tasoulas: Thank you for sharing that. I think it's a very unique perspective.

 

Daniel Deschler: This is the surgeon part of it. And then you blend that with “what makes a great academic surgeon”, and that's the person who's then able to take that component of being a great surgeon, and blend that with asking questions, constantly doing it in a critical manner, and doing it with the intent of moving the profession forward.

 

Jason Tasoulas: You make me wonder if I already shared my questions with you, without me remembering! Because my next question says “you have a legacy of training many excellent surgeons and surgeon scientists. How does one become a surgeon, scientist? And what should they do during residency, fellowship, and junior faculty years of their career?”. You obviously already touched upon that, but I'm wondering if you have more thoughts about this.

 

Daniel Deschler: I think that the key to being a great surgeon scientist is always being curious. You should always be asking questions. But you're marrying that with the discipline of how to evaluate and explore, and then also sharing the message. That involves seeing how people answer questions around you, looking at the machinery for answering questions and then doing it. So you need to do it from the beginning. Not just tell someone to do it. And I think that sometimes there's a gap in that.I think you need to know the all the steps in the production line. And that means you write a lot. The only way you get better at writing is by writing. I think some people bristle at that, but I think it's really important. And I've shared this with other people: I don't love to write, I don't! But I knew that in order to be impactful in this I needed to learn how to write, and then how to write efficiently, how to write well, how to advise other people how to write, and then from that how to edit. And those are all things. I think I do well now, but I do well, because I've done a lot of it!

I was the Associate Editor for the White Journal for head and neck surgery for over 8 years, and that made me good at that. Then I got this position with Up-To-Date. And so I've been an Associate Editor with Up-To-Date for over 20 years, and that taught me how to produce work for generalists, which my wife was very helpful with as an academic general medicine person. It also taught me how to teach other people how to write for generalists.

It's funny- I would ask people to write a piece for Up-To-Date, and and then they need to revise it, and they would bristle a little bit by the added work. And I would say to them “do you understand that in a given year 50,000 people will read your Up-To-Date chapter, and maybe 50 will read anything else you've ever written in otolaryngology? Your moment of impact is huge in that setting”. And sothat's a learning curve, too.

I think when you're a mentor for those people you have to be very specific about what your expectations are and what their expectations are. You need to know where they are on the curve of writing: with a resident, you're at one level, with a fellow you're at another. You really should set up goals and timelines. Then when you edit work, you need to explain why you're doing it. You explain other ways of coming at the question. Little things you can do. You demonstrate that every time your name's on a paper, there has to be a reason your name is on that paper, right?

 

Jason Tasoulas: I think this is a rare breed of people that would always review, always read, always provide feedback. And it makes a big difference for someone that is on the other side of this.

 

Daniel Deschler: It makes a huge difference. And you're going to do this, you'll do more and more of this, and then you'll start reviewing for journals, and then you'll have a lot of journals that'll ask you, and then you'll sort of find the ones that you do the most work for. It's okay to concentrate on those. Then, when you do that, those people at that journal will notice your work, and then they'll ask you to be on their editorial board, and then from there you'll develop that relationship, and then they may ask you to be an associate editor. But you can't do that for every journal right?

And because you do it for, let's say, Oral Oncology, it doesn't mean you never review for Laryngoscope again. But you just have to be consistent about your workload and how you balance that. That's the pathway.

But the biggest thing I tell folks is it takes time, so don't be impatient! Do good work, do it for the right reason, and it will be recognized, and that is how you can then be in a position to make a difference. If people shoot too fast, too quickly, then the foundational stuff isn't there, and things can go awry. But you have time! So it will all come together.

Jason Tasoulas: This is really great advice! You have held several leadership positions. You talked about your editorial roles. But obviously you also had leadership roles at Harvard Medical School, Harvard College, and AHNS to name a few. What are you looking for when you're either hiring someone on different levels, or when you're starting to collaborate with someone. What are some qualities that you're looking for?

Daniel Deschler: I think a way to approach this is to say, you're building a team to succeed at a certain project, whether it be the international meeting, or whether it be a division, or whether it'd be a specific project within a organization like the Thesis Committee for the Triological Society. You really want to look for people that you think share the same goals, and will be on board with the mission of what you're looking to do. You need to be able to clearly articulate that mission so that people don’t wonder why they're doing something.

I think you really need to connect them to the product, connect them into the success of the entity when it happens, for it to continue to succeed. You need to have people connected to that, building success as it goes forward, so they can have the positive reinforcement of putting in the time, because many of these are voluntary. I look for people who are honest, curious, passionate, who aren't afraid of hard work. I think that there's nothing wrong with working hard and doing something good with that. I don't think you're a fool or being taken advantage of, or anything like that. I think that most success is built on hard work, and if you look at anyone out there that you probably interviewed, like Bob Ferris, worked extremely hard and he still does. Look at Greg Farwell, another really hardworking person. But they were able to build teams around them, build consensus, and then carry those teams to success by listening to them, building upon their strengths. I don't even think leadership is the word- I think that what they provided was guidance, so that people can be in their best position to succeed. And you know that's really rewarding when that happens!

Jason Tasoulas: It's been a while since I did my interview with Dr. Ferris, but I remember he was still back at Pitt, he wasn't at UNC yet. And I asked him at the time “How do you do all three? You have a very successful lab. You're very busy there. You have a leadership role at the cancer center, and you're also clinically active. How do you do that?”. And he told me, and I still remember to this day “I'm 75% clinical and I'm 75% research”.

Daniel Deschler: Exactly! I've never had an academic day in my entire career. So I think what Bob is saying is that you just blend these 2 entities. It's not that you're working twice as much as everybody else, it’s that you're working on both things at a high level and that they're inextricably bound. They're woven together like threads that go this way, and threads that go that way: you need them both to have the fabric, And Bob is amazingly successful at combining these.

 

Jason Tasoulas: And would you say that those qualities that you described earlier apply to clinical work as well?

Daniel Deschler: Yes, I think that  excellence is not an accident.. It doesn't just happen. It happens because you are committed to it. If you have some special skill, that's great, but that's not going to carry you for the whole thing. Just because you're a little more manually dexterous, that's not the thing. The decision of where to put the stitch, or when to put the stitch is much more important than putting the stitch. And so I think that whether you're in the OR, or sitting at a lab meeting, you just have the same standards.

Now  that can be really challenging to the people around you, right? Because maybe some tasks don't need to be at that high level. But this is what you are like-  you can't deliver at a lesser level. And so that's where I find that I have to learn about my environment and say “Okay, you know,  people are trying, and it's gonna be fine, we're gonna do this right”.

You would much rather have somebody who feels like they are functioning  well, than somebody who feels like they're failing, because you're never going to get them to move forward. It's unfair to them to make them feel like that. So I think that's the thing that it took time to for me to learn, and I and I'm still learning, but it's very rewarding when it works out.

Jason Tasoulas: Thank you for sharing that. So MEEI, near is obviously a very special place for otolaryngology. It has been the driving force for many of the advances in our field, and even the people that went on and created other legacy departments are somehow related to MEEI. My question is what makes it unique for you.

Daniel Deschler: The thing that I like the most about it is that it reminds me of being in a small town. When I have a patient comes in from Maine, and they've driven 4 hours, and they have something bad, and they need an FNA, and maybe a scan - I can walk to radiology, or I can make a phone call and they can fit them in. If one of my patients comes in and they've got a sinus issue that now needs to be addressed, I walk down 2 flights of stairs to the sinus clinic, and I say “Hey, I got this guy. He's got this this and this. Could you see him to take care of his new sinus issue?”. That means a lot to that person at that time. And that also allows you to connect people to the core mission at key moments. So if somebody does a favor and does an FNA for me, I can thank them, but I can also tell them how important it was to the individual they took care of and so that they actually get some of the positive feedback that patients give, that they might not otherwise get. That's helpful to the people doing it and its much more possible when it's a smaller place.  So this is nurses week- and every year, on Wednesday night of nurses week I go to Trader Joe's, and I buy bouquets of flowers, and I drop them off to the OR, pre-op, PACU, the main floor, etc.

Jason Tasoulas: That's just amazing.

Daniel Deschler: It's a little thing that says thank you. And I can do that because MEEI is containable- it's not a thousand bouquets. It's 8. So that's a totally doable thing. But you know it's a way of connecting with people in that way. So when things reach a challenging moment, a crescendo, you've got people on board who will want to step up, and they'll do it for the right reason. So that's what I really love about working in this place. I've had the same 2 amazing women work for me as my assistants for nearly 20 years, and they do a great job.

So today, because I'm away next week for the Trio/COSM,  we saw a large number of people between 8am and 4pm. When I leave on a day like this I usually say  “Thank you for helping these people today. Great job team!” and let them know they are appreciated.

The other part that's fun,  is that you can treat this hospital  like a laboratory because of the fact that it's not multiple different services it is a smaller containable enterprise.. Around 2004, wwe really made a big effort towards trying to decrease the amount of time it took to do free flap surgery and have it be a reasonable thing. So we looked at critical issues of how we could carve time out here? Not just by making people operate faster, but by making the whole enterprise work better. When you have a small hospital and you're one of the bigger services in it, you can treat it like a lab. You can pull one variable out and address that variable, and you can see what happens. When laryngectomy tubes with HMEs were introduced, we looked into that, and we worked with nursing to set up a protocol, and all my patients got HMEs and all patients of another surgery did not get HMEs, and we directly compared those groups.  You can't do that in a big hospital where patients are spread out over many floors.. I could negotiate for many more things with the hospital because I could demonstrate downstream benefit for it. And so that that's been kind of a fun aspect of improving clinical operation through leveraging the size and the relationships within a small hospital.

Jason Tasoulas: Yes, it sounds like it's a very unique environment. And it probably brings a very unique sense of community with it, as well.

Daniel Deschler: Yes, but the thing is, that it’s good, but it only becomes great if you take advantage of the opportunities it affords. If you just go and say “Oh, I get to do more surgery”, then that's kind of a level one way of approaching it. But if you say “okay, I can do more. What are we going to do with the more we're doing?”, “Okay, that gives us more tissue for bio-banking. That gives us more cases to look back on for results, or that gives us more ways to look at how we're doing this to do it better, faster, cheaper”, that's when it's great. It's good, but to make it great you need to leverage that, to create things and make it better for others who aren't in your position.

Jason Tasoulas: Thank you so much for that. I'm thinking that what comes across through many of your answers is the sense of big picture vision which I think is rather impressive. So thank you for sharing this. Now I'm under the impression based on what I've what I've read, and our interaction so far that you have other interests outside medicine. And I'm curious to hear more about those. And how do you keep up with those while maintaining a very busy professional life?

Daniel Deschler: I have a very fortunate life. I think that people talk about work-life, balance, but I never liked that model, because in my mind it puts the two on opposite ends of a spectrum.  I've always felt that it's more like work-life integration. And I think that that's the better approach. What things are important in your life, how do you blend those together so that you can have each of them be rewarding and successful. Now, some days you're going to fail at work, and some days you're going to fail as a father. And you learn from those things and try to do it better the next time.

In my early career, the big drivers were my work, but also my family.  I was very committed. My wife and I, both, as academic physicians, made very important decisions about how we would approach family life.  We ate dinner as a family every night. Now that meant that we had to get home on time, and we had to learn how to cook a quick meal, but all  4 of us would sit down every night and have dinner, and then we would take care of the kids and get them to bed. Then around 9 o'clock is when your academic stuff starts. It wasn't while they were up. They had our time during that!

You learn how to construct your schedule so that they have consistency in their lives. So that may mean that there's a committee position you might have to say no to, or it may mean thatone of you does accept something that's seems really important, and the other one is on board to do that. So, my wife, was on the Resident Review Committee for Internal Medicine, which is a huge job, for 6 years: 4 trips a year, and so she could go, and we would work out.. And when I would have to go to the Academy or AHNS she'd cover for me etc. I I really enjoy my work. I take a lot of worth from my work, but also the family life is wonderful! I coached little league for 6 years when my boys were little, and I wouldn’t trade that for the world.

Back in the 2000s the talk I used to give was called “Making the Extraordinary Ordinary”, and it was the steps you do with free tissue reconstruction, that take it from a 16h operation to a 6 or 7h operation. People think it's just that surgeons get better at it. But that's not what it is. That does give you something, but when you then break down where the time loss is, what you can get by skilled teams working together, how much each component of it should take, what other forces play in the hospital - that's how you get it down to a 6 h operation. And then, if you do that, then your free flap surgeons aren't being burned out. They get home, and their families are happy, and then their kids know who they are, and then they can do it for a long time.

If you have people who do it for a long time, you go from competent to proficient to excellent, and then you go to mastery, and then, when you have mastery, you have people who can train people and skip the redundancy that often occurs. But if you don't do that, then what happens is people go from competent, to proficient, maybe excellent and then they quit, because other forces come to play. And then they keep cycling out like that.

But you have someone like Derrick Lin,), who’s still doing a ton of free tissue transfer. He's doing it because he can do it fast and well. And it's a manageable thing with his multiple other jobs. And that makes him a really important factor for the hospital, for patients, for academics, and so on.  He is a master.   

So I think that for me, you just have to find out what's important in your life. What gives you joy. And it might be art, it might beanything, maybe family and friends and loved ones, teaching, or something else! And you find places for those, and you do them at a level that keeps you going.

Jason Tasoulas: Dr Deschler, what are you looking for in the future? Professionally.

Daniel Deschler: I don't know if I'm really looking for anything right now. I think that I'm looking to continue to have leadership roles that can allow me to grow, but also to benefit other people. I'm looking for ways to make a positive difference. I think that's what I'm looking for. I'm not really looking for titles, and I'm not looking for accolades and things like that. I'd rather just say “Hey you know, where can I make a difference?” and then you can do them at a small level, and you can do them at a large level. Those are the things that I'm looking for right now, and that's why my wife and I took this this Dean positions  at the HarvardCollege, because it was really a unigqie and amazing chance to have a positive effect on a whole new group of people at an important part of their lives. We've been fortunate that those opportunities have come up in our lives. For example, I wasn't looking to be one of the people that led the International meeting. But then, something came up and they needed somebody. So they asked if I would come in and help with that, and it was a great experience!

 

Jason Tasoulas: Yeah, that must have been an incredible experience!

Daniel Deschler: It was a rapid learning curve for me, and I utilized my experience putting together  previous meetings.. And then you have to listen to people tell you what's important. And Bob  Ferris was very helpful with that. Again, not something I was actively seeking, but opportunities present themselves. And then you can decide, you know, can you do a great job with this, and sometimes you have to say no. For example yeasr ago  I was asked to be a Chair, and it really was a great opportunity. But ultimately it came down to not being the best time to move my family, and I had a great job here, so I ultimately said no to that. It would have been a career change for me, but I don't regret that in any way.

Jason Tasoulas: This part about saying no reminds me of what you said earlier about being able to tell when to operate and when not to operate, and how the latter is very important. I have a last question for you. This is a question that I've previously asked Dr. David Kennedy, and Dr. Carau. How would you like to be remembered? What would you like your legacy to be?

Daniel Deschler: I would like to be remembered as someone who really cared and tried to make a difference in any way I could. And then, if people are able to name a few ways, and if few different people name different ways, then I think I've been really successful. If that were to be the case, I'd consider myself quite fortunate, and having done well.

Jason Tasoulas: Thank you so much, Dr. Deschler.

 

Dr Kennedy - Thomas Jefferson University

 

                David W Kennedy, MD

Professor, Department of Otolaryngology- Head and Neck Surgery,

Sidney Kimmel Medical College at Thomas Jefferson University

Emeritus Professor of Otorhinolaryngology- Head and Neck Surgery

University of Pennsylvania

Dr Kennedy earned his MD from at the Royal College of Surgeons in Ireland and completed a residency in Otolaryngology-Head and Neck Surgery at Johns Hopkins. He pioneered endoscopic sinus and skull base surgery, and the medical and surgical management of chronic rhinosinusitis. Dr Kennedy developed the first rhinology fellowship thereby introducing the subspecialty of rhinology-anterior skull base surgery. He was recognized by the American College of Surgeons as one of the most influential surgeons of the 20th Century.

 

 

Jason Tasoulas: Dr Kennedy, I was going to start with my with my first question about the early years of your career. I mean, obviously, this career ended up becoming one of the most important in the field. I'm really curious to hear more about the early years. what made you choose Otolaryngology and what made you choose Otolaryngology in the United States in particular.

David Kennedy:  I'm originally from the British Isles, as you probably know, and I did my medical school and my internship in Dublin.  For internship, we do six months surger and six months medicine. When I was halfway through my  surgical block, the Professor of Surgery came  came up to me and said, David, you've been offered a job at Hopkins. You've got two weeks to make up your mind. I had actually never applied or really thought about leaving Ireland. It did seem like a good opportunity .so, I said yes. What I didn't know was that there was actually a secret agreement for me to go into the Cardiac surgery program at Hopkins afterwards and go back to Dublin and be the cardiac surgeon. And cardiac surgery was not what I really liked by any means. I had an uncle who was an otolaryngologist and., very successful in Dublin and I liked otolaryngology as a potential area. So, subsequently I had the pleasure of telling my chief of surgery at Hopkins, that I was not going to go into the cardiac surgery program and I had decided to do otolaryngology. It was certainly not popular with him.  In fact I don’t think that he talked with me again after that!

 

Jason Tasoulas: I can imagine..

David Kennedy: So then I ended up doing my residency in otolaryngology at Hopkins. Someone dropped out of the program, so they offered me to go in a year earlier than originally planned.  I decided to do it as long as they gave me time off to go back and do my surgery and otolaryngology fellowship exams in the in Ireland.. I wanted to get made sure that I was able to go back there if I wanted to do that At that point in time that was my plan post residency.

 

Jason Tasoulas: Υou said that you were offered the a job without you applying. You went to Hopkins, and this was for a general surgery internship. And then you would decide what subspecialty within the surgery. Correct?

David Kennedy: So in those days, you had to do General Surgery before you could do Otolaryngology. Most programs only required one year of General Surgery. Hopkins actually required two years of General Surgery before you went into the Otolaryngology program. So I went over to Hopkins, actually as a PGY2 in General Surgery. And for someone who is coming from overseas only having done six months of surgery, and basically having done almost nothing surgically, it was a trial by fire because suddenly I was told by my chief resident “this is your list for tomorrow - I won't be able to be in the OR with, you'll have an intern with you. We will meet at the bedside and discuss the cases”. This is what we did. We met at the bedside at 2:30 a.m., and we went through the cases for the next day. Pretty much every day. He was a chief resident who slept in the hospital, as was not that uncommon in those days. I didn't get much sleep either, needless to say. But it gave me a great surgery experience. I mean, my first day of surgery at Hopkins was a below the knee amputation, a trans-metatarsal amputation, and an incisional hernia. I remember it well.

 

Jason Tasoulas: That sounds quite like quite an experience. Did you also have to stay at the hospital?

David Kennedy: So I actually was staying in a dormitory just across the street. In those days, you were on call or at work enormous numbers of hours. On the ICU rotation, you didn't leave between Sunday and on the following Saturday. So you were there on Sunday morning, and you stayed through until you went for your resident lectures on Saturday morning. And then you got off Saturday afternoon and that was it. It was it was pretty much a trial by fire.

 

Jason Tasoulas: So it's quite different.

David Kennedy: It was not that good in some ways. But the advantage that you got to really learn to take care of the patients 24/7 and to be totally responsible for them. That was the advantage that you got out of it along with a lot of surgical experience. On the other hand, the fatigue was pretty terrible. I can remember falling to sleep talking to a patient in the ER and then he woke me up.

 

Jason Tasoulas: So you decided to go into Otolaryngology. You finished your PGY2 in General Surgery, and then you went to Otolaryngology. And that was for 3 or 5 years?

David Kennedy: In those days, it was four years, but the last year was actually an instructorship. So the total training was six years, two years of general surgery and then four years of otolaryngology. At Hopkins, the last year you were an instructor. So you're sort of a junior faculty member, which was actually a great experience and a lot of responsibility.

 

Jason Tasoulas: A few weeks back, maybe a couple of months ago, you gave a wonderful Grand Rounds talk in our Department, at Jefferson. I know a little bit about how and why you got into Rhinology and Skull Base, but for our readership, I will just mention that you said at the time, that you were thinking to actually become an otologist. So I was wondering if you can share that story.

David Kennedy: So I actually was an otologist! I said we had that last instructorship where we had some flexibility in that year. I actually ended up spending the majority of the year doing otology-neurotology, and then became one of the otologist-neurologists on the faculty at Hopkins for several years. In that role that I had a joint appointment in Neurosurgery. So they would also call me to do the trans-sphenoidal approaches because I was available and I was on their faculty as well. And so I wrote up our Hopkins transphenoidal experience going back to Cushing in 1912. And it had some really great drawings in it, because we had some old drawings that were done at the time of Cushing. And so the publication got some publicity, and I was asked to present it at a meeting in Europe. It was a sinus meeting, and I really did not want to go. I had nothing to offer and wasn't interested in the sinus field. So my boss actually bribed me with the ability to spend some time with my parents on the way there, in the UK, if I went. I went and there I met Dr. Messerklinger, and that really changed things. He had done a lot of research on mucociliary clearance, and I was able to talk to him because my resident research rotation had been on mucociliary clearance in dogs. I got interested in what he was doing, he was starting to do some surgery and I made arrangements to go back and visit him and also to visit other people in Europe who were starting to do some endoscopic surgery, and spend a little time with each of them, once I had also developed a little experience

 

Jason Tasoulas: And how do we go from this early this interest early on to developing essentially a whole new field? We, to a great extent, use endoscopes today because of what you did. What did it take to get this to become the standard of practice. Did you face a lot of pushback from the establishment? How was that for you?

David Kennedy: Yes. There was a lot of pushback. On the other hand, sinus surgery had high morbidity in those days. With open sinus surgery, the results were not that good. It was pretty obvious to me that we could do better. We got some experience and I asked Dr Heinz Stammberger to come over and do a course with me. We then started putting on courses at Hopkins and later in Graz, Austria. They were sold out. And the people that came were very, very interested and wanted to be early adopters.

On the other hand, at a national level, I had a huge amount of pushback. Both people that published against the new techniques and lectures where I got pilloried for talking about these new techniques. So it was a mixed bag, and sometimes pretty tough. There were early adopters, and there were those established people who really did push back very hard against these different concepts. And I think actually it was probably more eagerly adopted overseas than it was in the United States in some ways. We did a lot of courses overseas and  they seemed to be very well received over there. And there were early adopters in every country, I think.

 

Jason Tasoulas: Was it mostly Europe or other places as well?

David Kennedy: No, no, it was all over. So it was obviously difficult for the developing countries to get the equipment. But no, it was really all over in the East and elsewhere. Japan actually was early on doing some excellent endoscopic sinus surgery techniques under local anesthesia. So there it really took off. I've had a great relationship with the Japanese Otolaryngologists ever since.  It was actually in a meeting in Japan where I first introduced the concept of endoscopic orbital surgery.

 

Jason Tasoulas: And what would you say was the tipping point, if you can identify one that after that you were able to overcome the pushback.

David Kennedy: I don't know, I think slowly people started to take it on. And even people who had really objected to it early on, soon found that they needed to say that they were doing it, even if they weren't! So we found people who were doing it primarily with a headlight still, but would pick up an endoscope, and then they would say they were doing endoscopic sinus surgery. We know that that was absolutely not true. And in fact, one very well-known sinus surgeon from New York published his results on doing tumors endoscopically at a time that I know he never did a tumor endoscopically!

 

Jason Tasoulas: So they slowly started to to adopt.

David Kennedy: Adapt and adopt. Yeah!

 

Jason Tasoulas: You mentioned tumors. I know that within the field there are two main “subfields” -and maybe this is not an appropriate term. There is sinus surgery, and there is anterior skull base surgery that includes the oncologic surgery and the more extended approaches. I was wondering what your thoughts are about the development of the field from now on. And if you see this going into two distinct fields with allergy and sinus surgery being one, and skull base being another, in close relationship with head and neck, or if you see them remaining as one. What would you foresee for the future?

David Kennedy: That's a very good question, Jason. The answer is, I really don't know. It is obvious that there are not enough skull base cases for everyone in every institution to be doing them endoscopically and maintain good skills. On the other hand, I do think that fellowship trained rhinologists do better complicated sinus surgery. And the more complete sinus surgery you do, the better the results. So it is possible that that it will split into the two areas. I'm just not sure at this point in time whether that's going to happen. But it's an interesting concept. I think the question is, can the general otolaryngologist really get trained well enough to do perfect sinus surgery? Because it really does need to be done extremely well. And are they willing to take the time to do the necessary medical therapy that's required to manage a chronic inflammatory disorder. I don't think we know that at this point in time. There are certainly some that do it really, really well. But that's not true for everyone.  I think that this concept of ongoing management of difficult disease is particularly important as primary care moves towards mid-level providers who are likely to have less familiarity with otolaryngologic disorders.

 

Jason Tasoulas: I see. So you're saying that it definitely requires or most likely requires a fellowship to be able to adequately manage those conditions, but it's not necessarily true that we will end up splitting into two separate fellowships.

David Kennedy: I don't think it necessarily requires a fellowship, but it does require a, some a at least a fairly special interest  to really manage these patients well. And we need to manage them so that they don't get recurrences. And I think we can do that with the spectrum of medical therapies that we now have available.

 

Jason Tasoulas: You’ve been through and been part of all these transformative experiences in the field.  What would your advice be for residents in training? How can we get the most out of training? What should we focus on? How can we balance research and clinical training? I really want to hear your advice.

David Kennedy: During residency, obviously clinical care is critical – both surgical and medical.  I think there are two other things that are important. One is the numbers of papers. And I think that people do look at the numbers of papers and it's important to put out papers, even if they're clinical and not of major significance. But I also think it's important for a resident to get involved in at least some translational research. Because if you want to go into academics afterwards, that's going to be the basis of what you do subsequently. So, I mentioned that I did mucociliary clearance work on dogs with Dr Proctor at Hopkins, and I had no idea that that was ever going to be important to me later, planning to be an otologist. But it turned out to be extremely important. It was the only reason that Dr. Messerklinger was interested in talking to me, because we could talk about the mucociliary clearance aspect and how that really worked, and obviously that then translated into the whole concept of doing things endoscopically.

Jason Tasoulas: You mentioned papers is one, but you said there is two things. What would be the other one?

David Kennedy: It would be to try to get involved with some basic research. I think that that's important. Try to find a mentor that you can work with, to do some not necessarily basic, but at least translational research, something which would later give you a leg up towards developing a research area during fellowship or even as a junior faculty member somewhere. I think that's really very helpful.

 

Jason Tasoulas: And what would you say about the balance between clinical training and clinical developing a clinical skill set and a research skill set? How important are the clinical skills and how one should balance between the two?

David Kennedy: The clinical skills are obviously paramount. We used to think of surgeon scientists being 50/50. And that really does not work well. So what you really need is someone who has superb clinical skills, but can maintain them on perhaps only 30% clinical practice. And that's not everyone, by any means.

 

 

Jason Tasoulas: I see what you're saying: a good starting point could be 50/50, but then the research component would ideally maximize as you develop the ability to maintain your clinical skills by doing even less than 50% clinical.

David Kennedy: Yes. I think if someone wants to go the R01 route to get basic research funding, they need to be more than 50% research. But that's not the route that most people will go in academic medicine.

There are a few that do that- one of my former residents and fellows, Noam Cohen at Penn, did this very well. He's someone with superb clinical skills, who can maintain a clinical practice but be primarily in the lab. And, that's not the way for most people. For most people, it really is being primarily clinical, but also understanding and cooperating and having that desire to work with people in basic science to bring the area forward.

 

Jason Tasoulas: I'm curious to hear what your opinion about that is, but I see two models now for surgeon scientists. One is the surgeon-scientists that do run their own lab themselves, and the other one is that some surgeon-scientists work with a PhD, and they co-run the lab while spending some time in clinic while the PhD is 100% research.

David Kennedy: So I think there are very few people who can do clinical and spend most of their time in the lab. That's really few and far between. For the majority of us in academics, it's understanding research, having a background in research, and then knowing where you want to participate. I think getting a K01 as a junior faculty member is really very helpful, providing that background. The concept of the K01 is really for someone who's going to go and develop an R award—I don't think that's necessarily the way that everyone needs to go. I think the K Award helps you cooperate with people in basic research and provides that background and enables you to put input into people who are primarily in the lab. I mean, it might be your lab, but in many cases it will not be, but you've got to have good basic scientists.

 

Jason Tasoulas: I see what you're saying, and I think, or at least my understanding from this very junior standpoint that I am on right now, is that surgeon-scientists are quite a rare breed. And I'm wondering if you think they will still continue to exist, at least in major academic institutions, or if it's a dying breed. I know that there are some concerns from people that it's not sustainable to be good at both things. And obviously you and other people are an example of the opposite. But do you think it will continue to exist and Departments will continue to seek out these people with this dual training background?

David Kennedy: Yes, I absolutely do think they will continue to seek that out. But as I said, I think it's for a very limited number of people because it's difficult to maintain surgical skills even within a small subspecialty. Unless you are pretty talented with only about 30% clinical and having a limitedfocus of expertise. It's much easier within medicine, where you don't have to practice surgery, but within surgery it is difficult, because of the importance of maintaining surgical skills. But yes, I do believe it's going to continue. I think that places are going to look for people that can do that. But I think for the majority of us, it's understanding research and being able to participate with basic scientists who are doing that area or doing innovation, which is the other thing I think is really important within the specialty.  There is still plenty of room for innovation and cooperation with industry.

 

Jason Tasoulas: Besides leading the Oto-HNS Department at Penn for many, many years, I know that you've had healthcare leadership experience as well as the vice dean at UPenn. And I was wondering if you would be willing to discuss a little bit about that. How different is it to manage this side of things compared to a Department? And what did you learn from this?

 

David Kennedy: So I think it was actually really very similar. You know, if you run the department well, it really is a very similar experience at the health system level. It was helpful for me, I think, to find out how to run other Departments, other clinical departments, what the issues were in other clinical departments, to try to introduce appropriate reimbursement for the physicians in other departments so that that became a bit more standardized across the health system, and also how to standardize appropriately  the support for different Departments, so that it was  more fair. Prior to that, I think it had been whichever chair negotiated best ended up getting more support. What we tried to do is to really standardize it and put out a model within academic medicine for providing support to the Departments and making it, you know, one size fits all across the health system.  We also moved towards standardizing incentive systems and productivity expectations at the faculty level, so that it was more fair and inline with market expectations. It was also nice to participate in the health system development, satellite strategies and the design of a major new institutional outpatient center.

 

Jason Tasoulas: And do you think that the same people that are running the show from a research standpoint, meaning the surgeon-scientists, the highly accomplished academicians, can be the same people that actually lead and take the managerial positions as well? Or in your mind, are these usually different types of people with different characteristics?

David Kennedy: So when I went from Hopkins to Penn, I had to really make a decision. I didn't think that I could be a real triple threat with the time available. So basically, I gave up research at that point in time. I think I gave up research to do administration and clinical work. That was a tough decision. I think I could have also done research and administration. But I think what the clinicians look for is someone who is active in that area. So for me at least, I didn't feel I could do all three. I made a difficult decision, which was to basically give up the research area, obviously continuing to publish, and work with others. But I gave up all of the basic research that I was doing when I took that position. And I think, honestly, in this day and age, what the chair position is, is primarily is administrative and clinical. I really do. But they've got to have that background in research to know how to keep that element going and really get a good vice chair for research as well. So there is someone to lead the research endeavor.

 

Jason Tasoulas: During your career, you've hired for positions at all different levels. And I'm curious to hear, what are you looking for when you're hiring someone, whether it's at the resident level, junior faculty, or senior faculty? What are the characteristics and qualities you're looking for? And I understand that they might be different depending on the position, but I’m wondering whether there might be a generalizable theme there for you.

David Kennedy: Well, obviously the first thing you look at is the CV, and that gives you a background about whether they are willing to push themselves. And that's why I say, as a resident, the number of publications is important because you want someone who is pushing themselves. And that's probably the first level that you look at. You want to find out, do they have good clinical skills if they're looking for a clinician? And do some follow-up on that. And then how they're going to fit into the Department is obviously really critical. One of the things that the former Dean at Penn used to do when hiring Chairs was always to do a reverse site visit. And I often thought if I was in a Dean position, although it was probably a day or two days away out of your Dean time, it was actually worthwhile because you would find out things about people by talking to others – for instance how they treat people under them. When you're looking at the Chair level, that's so important for an institution not to make a mistake in who you hire as a Chair. So, I actually think that he spent his time well, doing that. And if I were a Dean, I would, I think, recommend taking that time out to do it. You find out from assistants and research associates and, you find out from other people, you know what someone is really like. At a faculty level, I don't think that's so important. But as that Dean used to say, the chairs are really the princes of the kingdom, and you have to make really good choices for the chair.  A bad choice as Chair can be really expensive in terms of faculty and in terms of costs and lost opportunities to the health system.

 

Jason Tasoulas: So he would go on site and spend some time there and talk to people on all levels?

David Kennedy: To make a Chair decision. He would spend at least a day or so at the institution finding out the truth about the individual, things that are not in the CV and not necessarily in the recommendation letters, and don't show up necessarily during interviews.

 

Jason Tasoulas: How does the institution gravitas weigh in compared to the residency program gravitas? So coming from a great institution versus coming from a great residency program. Those two do not necessarily always overlap. How does that weigh in on your decision? What would you prioritize?

David Kennedy: You mean looking for a faculty member?

Jason Tasoulas: Yes.

 

David Kennedy: I think you do look at where someone did their medical school and where they did the residency, but that's not really the ultimate arbiter of who one should pick by any means. And I think obviously you want someone with good clinical training. That's clearly true above almost everything else, but you also want someone who you think is going to be moving an area forwards.

When someone joins a faculty and then if they're later looking to move up and move to a different institution, it's what they do during their years on faculty that's more important than where they did their residency or medical school. We've seen people who did not go to great medical schools, but who have done extremely well. And I would put myself in that category, you know. I don't think that coming from the Royal College of Surgeons in Ireland as a foreign medical graduate is an ideal entree into the US residency or into faculty positions after that!

 

Jason Tasoulas: Well, I do echo that sentiment coming from a medical school in Greece. I'm an international graduate myself, as you know, so I can definitely understand where you're coming from saying that.

David Kennedy: Yes. And when I was program director at Hopkins, we had residents from overseas at Hopkins and fellows from overseas, and they have often turned out to be the leaders. So it's really not what's important. You have to look a bit deeper than that.

 

Jason Tasoulas: Dr Kennedy, is after this incredible career that transformed the field, what if you had to pick one thing, what would you like to be remembered for? What would you like your legacy to be academically?

David Kennedy: So the legacy has to be for the people you teach. I mean, it is what really makes you proud. I'm proud to have helped people who have gone on to be leaders within the specialty. And that's what's by far the most important. The people that you work with and what they think of you is really important, not what people overseas think of you orpeople who only see publications. . What you want is when people come and visit with you, you want them to find out that you're actually better than they thought that you were from the publications. And I think that that's important. So, teaching by example would be my primary legacy. Obviously, I'd like to be remembered for having reduced morbidity within chronic sinus surgery. But it's really primarily the people that you teach and develop relationships with. I was absolutely delighted a couple of years ago when all my former fellows had this huge thing for me in LA. And that's I think what's really very gratifying – and when they still say that they hear my voice in their head!

Jason Tasoulas: Dr Kennedy, my last question for you is why did you decide to go from Penn to Jefferson?

David Kennedy: So I was at Penn and I decided age-wise, it was probably time that I stopped doing surgery. And I think it was the right decision, although extremely difficult because as a surgeon, you just love doing surgery. But after I did that, they put me out to Penn Medicine, Washington Square. And there the equipment was not good for what I did. Beautiful building, but the equipment was really not good. I couldn't teach medical students because I didn't have video towers. I couldn't teach residents or even students with that level of equipment. And we didn't have a fellow there. As I mentioned, what I really enjoy within academic medicine is the involvement with the residents and with the fellows. Jefferson gave me that opportunity and involvement, and it the new Honickman Center is beautifully equipped.  The rhinology team is also excellent, so I have been delighted to make the change and I hope that it's going to go really well.

 

Jason Tasoulas: I can tell you from the resident side, we're extremely, extremely proud and extremely excited to have you!

David Kennedy: I'm. I'm delighted to be here. And it's it's great to be working with the residents again. And I'd love to spend more time with you guys.

Jason Tasoulas: Thank you so much for doing this, Dr Kennedy.