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.