Dr. Ricardo
Carrau, MD
Professor,
Department of Otolaryngology-Head and Neck Surgery,
Director,
Comprehensive Skull Base Surgery Program
The Ohio
State University
Why did you choose to specialize in Otolaryngology? What attracted you
in the field?
The short answer is that I loved the challenge of the head and neck
oncology- that is really what attracted me to the specialty. The challenge in
the operating room and the technical aspects: there is always a cranial nerve
in the way, or a vessel! I found it both interesting and challenging. Something
that fitted my personality. That’s the short answer. The long answer is that I
started in Internal Medicine- I really liked the field of Internal Medicine, in
regard to the knowledge they have, and their understanding of human physiology.
It was fascinating, but when I went on to practice Internal Medicine, it didn’t
fit me. All of my life I thought I was going to do something in internal
medicine, maybe Cardiology etc., so at that point I was a little bit lost. I
started looking at all the things medical students are exposed to.
Unfortunately, for me, surgical specialties were on my last rotation of medical
school, and by that time it was difficult to change; I had already been
accepted to internal medicine. As I rotated through the different surgical
subspecialties, I was attracted to many of them but at the end, the one that I felt
really fitted me well, and I was fascinated and passionate about was Head and Neck
Surgery. Once I started, I learned to like other aspects of ENT, like ear surgery,
laryngology, rhinology and everything else of what we do. I think at that time
I took the right decision- I do not regret it!
Is there something that you don't like about the specialty?
We deal with areas of the body that tend to accumulate a variety
of psychosomatic symptoms. Many times, there are patients that are difficult to
manage. They have a variety of symptoms but a disease is hard to pinpoint, and the
symptoms are hard to manage on a chronic basis. However, I don't see that much
of that in head and neck oncology. But in the other specialties like laryngology
and rhinology, you see quite a bit of that. That's the one thing that I don't
particularly like, yet it's a big part of what we do, especially for general
ENT practitioners- it is frequently what a big part of what you do in the
office.
But for head and neck and skull based in particular you, there is nothing that you can think of?
No, I don't. I don't dislike any of the aspects of, of the
head and neck or skull base surgery. I think that they are very fulfilling yet,
very, very challenging. The only thing that I regret and hopefully this will
continue to improve is our survival rate. It is psychologically very hard to
take that a good percentage of your patients, up to 50%, die of their disease
no matter what you do. We're making strides in that regard, but it's still
taxing, and psychologically it is hard to take sometimes.
I see. So, my next question, is about your subspecialty. Initially you did your fellowship in surgical oncology, and essentially you are one of the pioneers in what we call today endoscopic skull base surgery. So, what led you to this transition from mainly open surgery in the context of surgical oncology to the endoscopic one?
Yeah, we started as a concerted
effort to do that when I saw the endoscope as one more tool that we had
available to us. And at that time, I was doing some aspects of rhinology. including
inflammatory disease of the sinuses, and I was also doing the head and neck and
the skull base surgeries. It seemed like the endoscope offered another
visualization tool to circumvent some of the problems we were having in the
anterior skull base surgery. So, I started using it more. Like everybody else at that time, we started
using it for optic nerve decompressions, palatine artery ligations and orbital decompressions
and also frontal sinus surgery. That really prepared the scenario to use it
further in the skull base. Our first step was to really use it in hypophysis or
sellar surgery and that offered proof of concept that it could be done, that it
could be done safely, and that you could deal with the complications of the
surgery even if you did it endoscopically. We started expanding from there.
But at the beginning at least,
and maybe in the middle of it also, we were not looking for anything in
particular. We were just looking to do the surgery better, to see better and to
have better results. Then, we got to a certain point -I can’t tell you exactly
when that was, probably around 2005, 2006- when we had acquired enough skills
and enough experience to then think…okay, so where can we take this? And that's
when we started concentrating on the fact that this can be done to a much
greater extent. The endoscopic approach offers you a different angle, you can
combine it with this or that approach, and suddenly we were able to look at 360
degrees of the skull base.
How did it feel at the point that you mentioned that you initially started, when you began doing some proof-of-concept surgeries? I presume at that point it was uncharted area, right? It's not like you had someone to walk you through it. You were essentially the first one to do so. How was that?
Well, again, because we had
acquired the skills that I mentioned before, I felt very confident that we
could do the surgery. I also had the experience of doing the various surgeries surgery
with an open approach. For example, when approaching the sella, I had previously
used the transnasal and trans-septal approaches, so I knew what was involved, what
the endoscope was capable of and the skills that it required. The most
difficult thing was really to convince my neurosurgical colleagues that we
could do it. I started back during my time in the US Air Force just showing
them that after a trans-septa surgery we could insert the endoscope and look
around, providing a great view inside the sella that they didn't have with the
microscope. So that was the first attempt to persuade them. Then back in the
nineties, a colleague in Pittsburgh, Hae Dong Jho got interested in the
possibility and it took off. I remember that at the beginning we had the
microscope set up just in case we couldn't do it with the endoscope. So, we had
a backup just in case things didn't go well. After the first ten or so, we never
prepared the microscope again. We knew that we could do this, and from there
again, we moved into other places of the skull base. Even if we wouldn’t be
able to do it with an endoscope, we had a plan B or even a plan C to take care
of the problem.
I see. And once you essentially proved feasibility after a certain point, I understand that people got convinced that at least for some operations, the endoscopic approach is better, right? So, my question is how and at what point during this process were you able to actually convince people that this does not only work, but it's actually a better approach in some instances?
Yeah, so that's still in the
process! I think people have different indications and different biases for the
use of the endoscopic approaches. What is best for me, is not necessarily best
for another person; the choice is very individualized and depends on your
training, and on what circumstances you have. Endoscopy is a surgery that is dependent
on technology, dependent on instrumentation. So, if you are in a place where the
necessary technology and instrumentation is not possible, then even if you are
convinced that it may be a good idea, you cannot do the surgery. Still, there's
fairly a fair amount of controversy regarding indications and selection of
approaches for many of the diseases that we deal with. In our own group, we
have gone back and forth on what to do for certain pathology. You may push the
limit to a certain point, and you go and say, “oh, this is really maybe not
such a great idea, let's back off” and you go in a different direction, or you just
combine it with another complementary approach.
Reconstruction has been one of
the of the main aspects that slows down the process of spreading and accepting
the endoscopic approaches. It will remain an obstacle until we completely solve
the reconstruction-related issues. Again, you have to look at the person, place
and circumstances before you make the selection of the approach and that still will
continue to hold true. That's one of the reasons for which we’re still teaching
courses around the world, endoscopic approaches are slower to be adopted in
many places.
You mentioned teaching, and I really wanted to ask you how and at what point did you started implementing all these advances in residency training? I presume now it's a fairly big component of the residency training, but how did you started implementing this angle into training?
Yeah, I general it's more of a significant
part of the residency program in neurosurgery than it is in ORL. One of the
reasons is that it's a very specialized type of surgery. That is not to say
that the residents don't get their hands in the cases, but usually it gets to
the point that it is more complex, more challenging than what the level of the
resident skills is. That's also true for neurosurgery, but because they have a
longer program, they push it a little bit more. For both neurosurgery and otolaryngology,
it also depends on the interest of each resident, right? So, if you are going
to do laryngology, you may not be really interested in spending hours and hours
in a skull-base surgery case that you will never do again. However, if you're
going into that pathway, you will demonstrate more interest, you will be more
engaged and you will be able to advance and do more things than most of the
rest of us.
We take that into account in our
training what is the trainee desired pathway? What do you want to get out of
this? So, for example, in endoscopic skull base surgery, the resident usually
finishes the sinus part and then when it's time to drill the sella,
neurosurgery starts gets involved. In general, the removal of the tumor depends
on what type and extent. If it is a malignancy of the sinonasal tract is more
to the side of otolaryngology, and the fellow goes on to do as much as they can
do, or if it is a meningioma that will be more on the side of the neurosurgery,
it is the opposite. In every case, we work with each other, but we don't have
any particular boundary. We rarely say, okay, this is ENT, and this is
neurosurgery. Sometimes it depends on who is available at that time. In
general, once we are dealing with the circle of wills, I think that that's
better off in the hands of the neurosurgery team.
You mentioned the skull-base fellow. I'm curious to hear your opinion about rhinology/skull base fellowships. Do you think that the one-year fellowship is enough to gain a good grasp on endoscopic skull-base surgery or do you believe that two-year fellowships are better training-wise?
Yes, with an asterisk. If you are
starting from zero and you have never touched an endoscope in your life, I know
that would not be enough. Most fellowship candidates, including both
otolaryngology and neurosurgery, have had plenty of experience with endoscopic
surgery. So, by the time they finish residency, they're fairly familiar and the
one year is enough. Actually, we have had a couple of fellows that after the
first six months, I just go and tell them, “I don't know what we're going to
teach you in the next six months because you're doing already all aspects of
the surgery very well. You will continue to get better, but that doesn't mean
that you have any limitation”. Although it's somewhat person-dependent, we have
a selection process that seems to favor that type of scenario where at the end
of the year they are more than capable to do all the aspects of the specialty.
And again, that's not to say that they will not continue to improve and hone
their skills and continue to learn more and more, but that's true for
everybody, including myself. I'm still learning!
Yes, of course. Have you had experiences with people with a similar background to yours? I mean, people with a background in head and neck surgical oncology that decided to enroll in a skull base fellowship. And if yes, was that an advantage, or it didn't actually matter?
My bias is that it's very
beneficial because the head and neck oncology candidates usually have a very
deep understanding of oncological problems and oncological concepts. However,
they may be a little bit behind in the sense of the endoscopic skills as
opposed to a rhinology type of person that is very adept with endoscopic
skills. However, I do not divide my practice in endoscopic and open, right? I
do both, and I do hybrid, and I do head a neck oncologic surgery and I do some bread-and-butter
rhinology. At the end, I think that coming from either side is fine. Regarding the
outcome, I don't see a huge difference on the trainees at the end, even when the
beginning may favor one side or the other. I have had fellows with a rhinology
background that continue in their rhinology pathway, also doing skull base
surgery, mostly endoscopic; and I have had fellows that lean toward head and
neck oncology, so they do both the open and the endoscopic approaches. At the
end, they are all doing super. Furthermore, the ones that come from the rhinology
background, if they choose to do so, can have an experience with open
approaches throughout the fellowship year.
I understand. I would like now to change our subject a little bit and take it a step behind, from fellowship to into residency. I presume you are reviewing residency applications this time of the year. So, I'm curious to hear if you can think of things that can actually make someone stand out in your eyes and on the other on the other hand, things that are red flags for you.
Yeah. Let's just start from the
beginning with the process that we have right now. We’re asking a medical
student to be interviewed for a job that they had never done before. So, what
you are going to interview for is really to show your potential. Of course, if
you have a medical student that rotated in the department, you have been able
to observe that person a little bit better, maybe even glance at their
technical skills and their ability to interact with people. But for most, it's
really potential. So, for example, we get 400 or so applications and we give
around 60 interviews, from which we take five residents. It is a big filter. So,
what are we looking for? Well, we look at how they have done academically. The
examination is a proxy for discipline, hard work and cognitive power; but I
have to say that the candidates nowadays are just incredible. We have so many people
with high scores and academic proficiency that itbecomes sort of a baseline. Of
course, there are always exceptions -there is that individual that is in the
99th percentile of everything they do, and that's a special type of person. But
for the most part, most of our candidates are going to be between that 96 to 98
percentile. How can you tell then? You look at other things they have done,
maybe research and publications, also what type of research they have done. Has
that research turned into a paper? Again, that's just a proxy to show that not
only that you can do the work, but you follow it through, and you actually have
brought it to fruition. It's not just wasted effort. Then, you look at the
letters of recommendation and you look for what the people that have mentor or
have supervised that student, have to say, looking for key words. How they work
as part of a a team? How was their work ethic? How was their attitude? their
engagement during that rotation or during their medical school? And then you
look at other things like maybe they've received certain awards, they have some
leadership skills that they have put into action, volunteer work. These are
proxy metrics for personality, the ability to work in a team, degree of empathy
for their fellow human beings etc. So, that's basically what we look at. I have
to say that it may be very difficult to discern when you interview that person
because it may look very good in paper and then maybe they're not so much of a
people person. Maybe has an awkward personality that makes it difficult to work
in a team.
It may be that the intensity of
interactions is to low or much or too. So, you try to gauge what is really the
Goldilocks point for that person and whether or not they're going to fit in
your team.
I always say it's like speed
dating to getting married for five years. You're going to have an intense
relationship with that person for five years. So, you don't want to miss red
flags that will make the relationship go sideways. Red flags include: i) any
type of dishonesty. This triggers immediate elimination in my book, because if
you start with that type of relationship (and that's true for any personal
relationship) it is a really bad start that is due to get worse. You cannot
expect it to improve with time. Ii) interpersonal problems that the student may
have had that continue. I'm not talking about you got into a fight in middle
school. You know, that may be okay. That's not what I'm talking about. It's more
like, you got into an argument with your professor that ended up in
disciplinary action. That's not to say that you cannot get into arguments with
your professor. It is the type of argument and whether the argument is
conducted in a professional way. But if it deviates from what we call professionalism,
which involves emotional intelligence and involves certain level of maturity,
then that's another cause for elimination, I have to say though that this is
very rare, and when it is there, it comes up very quickly in their application.
So it's easy to pick it up.
This is relatively easy to pick
it up. Sometimes, once in a while, I have seen people that went through the
filter by being pathological liars; they just lied their way through the
system. I have seen people who are not really capable of sustaining healthy interpersonal
relationships from day to day, they start yelling at their peers, and the
nurses and the patients. That's not to say that they cannot perform in medicine,
but then we strongly suggest that they go into a non-patient care specialty,
generally they may do better in those! So I think that that's in a nutshell how
I look at it. It's not magic formula and it takes a lot of work. To this day we
have tried to find what would be the best formula for interviews, and to select
residents, yet we still don't have it quite completely right. Well, nonetheless,
that's what we use.
So you mentioned you mentioned research. I know there's always this debate, at least for early career stages, like residency applications, where you have quality versus quantity. And I understand that it's really hard to evaluate the quality in 60 or 400 applications. But I'm curious if and how that factors in. I mean, 10 case reports versus 2-3 impactful papers, how do you weight that?
If you have ten papers in Cell or
Nature, yes, it will put you in a completely different category. But most
medical students don't have that. They may have participated in really hardcore
research projects, but they are usually not the first author or even in the
first three. They just participated in it. Not to take that away value from them,
but for the most part, they have translational and/or clinical research, or
have case reports. Thus, you look both at the quantity and the quality, and
again, you look at what they have done to get there. So, I'll give you a
concrete example: If you took a year off and you went to NIH for a year and you
came up with a single case report, that's actually a negative. However, if you
are in a in a place that is not known for research and yet you are able to
produce a research project with a mentor, it’s definitely a positive. It may not
tilt the table completely to one side or the other, but definitely at the time
of considering all the qualities of that applicant, it comes out as a very good
thing. So yeah, that's true for anything that you may have achieved against
challenges. If you have a background of growing up in a rural area or in the
inner city in a background that is not conducive to academics and you still
fought and made it out, that's a big plus, because that tells me a lot about
the resiliency and the grit of that person, and how they're going to do in the
future. It's a very dominant predictor.
This is really interesting to hear because it sounds like you evaluate and appreciate where one begins from. And of course, it's not the same for everybody. And I'm wondering, have you had the experience with IMGs? Have you ever had one on your program? Would you consider one?
Yeah, we do consider IMGs. The
problem for the IMG is that they're going to be seen as a risk, as a higher
risk. With a student coming from the States, even when the education varies
from medical school to medical school, it is more homogeneous than what you see
in other countries. Of course, you use the exams as a proxy to see what the
potential is. Yet, that's still not enough to really overcome that you're
coming from another place, because they cannot judge you current skills as well
as in a native student. They cannot judge your potential as well as in a native
student. At least that's the perception. Maybe the perception is wrong, but
that perception is there, and you will have to prove beyond the reasonable
doubt that you are a great candidate. Because of the competitiveness of the
field, it becomes more of an uphill battle for the IMG to obtain a position. Usually,
I recommend to IMGs to rotate in the department of interest. Your best option
is where they know you the best, where they have seen you in action. That's how
you decrease the risk perception. At the end when finalizing the match list,
you may be in a position to match, even when you may not be in the first ten
spots in the list. You prove in that institution that you are the right candidate,
and they will match you.
It used to be the time that you
could do a year of general surgery and then be ready for to enter the ENT
program in a second year, if a program lost somebody in the process. I think
that this has been basically eliminated because of the way that we require
people to be trained during that first year. This used to be one of the best
pathways for IMGs to really be ready to go.
I see. But how can you eliminate the risk?
You have to look at the same things that I mentioned before that
we look at for the medical students. And you have to be ranked superior in all
of them. That's how you eliminate it. Being known personally helps, communicating
personally, rotating, engaging in research, Make yourself known not just in
paper, but in person to the programs of your interest.
And now I have a question that’s coming from a friend of yours, Dr. Georgalas. So he said “ask him what would he like to be remembered for?”.
Professionally, I think that I
will be really happy to be known as a good teacher and mentor. That's really my
legacy: the people, the trainees that I leave behind. To be a good teacher, a
good mentor for my fellows, my residents, for people that I have interacted
with, I think that would be the best. All the rest disappears, right? Endoscopic
surgery is the flavor of the decade, but it will be replaced by something else.
What usually happens is not that they completely forget about what you did, but
it will become just a historical point, sometimes not in a positive view. Each
procedure is replaced by something that is technologically superior and gives
better results.
Pioneers in the past are looked
at with some respect, but you don't really want to do what they were doing in
the past, right? You've got to do what is being done now or trigger what will
be done in the future. So, to some degree we're all going to be looked at as
barbarians for what we do nowadays, and hopefully that's the case. Hopefully
medicine will continue to evolve to the point that we will be considered
barbarians.
Otherwise, we haven't succeeded.
Yeah. So, what else is left?
Papers? I think that every single paper I have written becomes obsolete within
five years, maybe at the maximum ten. So that's not it. What else is left? I
want to be remembered by my patients as someone who took care of them in the
best way possible. That's powerful, is receiving any token of gratitude is one
of the most fulfilling things in my day-to-day practice. As a member of the of
Otolaryngology/Head and Neck Surgeons community, what I want to leave is a
legacy of residents and fellows that will be better than what I ever was and
that will continue to advance the field for the benefit of humanity.
No comments:
Post a Comment