Mobile Surgery: Part II

Innovation


Los barcos son segur os en los puertos,
pero no son hechos que dar allí.
Ships are safe in the harbors,
but they are not meant to be there. [1]
Doctors are comfortable and safe at Stanford,
but this is not what they were meant for.
Doctors are meant to help people

Welcome of new Stanford Super Residents at the release to the world of the freshly minted- by Donald Laub, MD at the commencement of Plastic Reconstructive and Hand Surgery trainees, June 30, 2012

[2]

 

 

 

 

 

 

 

 

 

[1] Personal communication with Dr. Jorge Palacios at the Surgery Preoperative Evaluation Clinic Porto Viejo, Ecuador circa June  30,  1984

[2] Oil painting of a cleft repair, done by Paige Labrie (1992)

The spirit of Silicon Valley, of entrepreneurship, lies in the virtue of being out of the box regarding innovation of actually changing the principle rather than simply modifying the application of the principle; this spirit was perhaps initiated for us by Leland and Jane Stanford our forefather and foremother, who were outside of the box in their method of breeding trotting horses. Stanford purchased the horse pictured above, “Electioneer,” in an obscure spot in upper New York. Two hundred additional broodmares had their home on campus not far from the Medical Center. His method was not recognizable by those in the ruling class of the trotting horse industry, and they termed these 5,000 acres and the university, the “Stanford Circus,” because to them, it seemed ridiculous.

When his new science of horse-breeding sired 166 trotting horses who ran the 1-mile course in less than 2 1/2 minutes [3], as well as the new champion the of the world, “Occidental,” Stanford’s confreres ceased to make fun of him, because he was both scientific and correct; Stanford was right. The world learned that being out of the box, being different pays off, provided you were right. The ruling class in plastic surgery called our first 5 trips to Latin America, the “Stanford Circus all over again.” The actual, initial purpose was the training of residents, as well as professionals in the developing countries in the field of international humanitarian surgery. [4] This essay is not EGO, I hesitate to talk about myself, but rather about some of the things learned over my forty-nine years here at Stanford. I am going to tell you things that may be
helpful to you.

[3] “The Stanford Equestrian Team.” Stanford Red Barn. The Stanford Equestrian Team. Web. 28 Jan. 2013 < http://set.stanford.edu/barn/history.htm&gt;.

[4]Ross Musgrave, Professor of our National Society, & Professor of Plastic Surgery, University of Pittsburg (1971)

Dr. Jim Chang, Head of Surgery at Stanford, and Dr. Ron Iverson, President of ZedPlast, the Stanford Plastic Surgery Alumni Association, have maintained the tradition at Stanford of taking multi-disciplinary surgical teams to developing countries, focusing on a single diagnostic challenge. In fact, we at Stanford, Plastic Surgery division, claim primacy as being the first ones in medical history to do such. Over fifty-eight foundations or medical schools (see list) now carry out this work, not propter hoc, but post hoc (not because we were the first but chronologically following our work) starting 1968.

We welcome the new recruits into Stanford Surgery, and to this tradition: the 20 lucky students in course Surgery 150: Global Humanitarian Medicine. You constitute the next generation. We know that the future years of yours and of ours will be fantastic. I hesitate to talk about myself.

I arrived here at Stanford just as you are now, ready and eager for work, fit physically, intellectually, and spiritually. Because I was from the Midwest, I was programmed to have three great advantages: ability to work hard, hard, hard, a desire to help others through plastic surgery, and my third, and greatest, advantage was Judy Laub, my wife who has helped me through thick and thin, and guided me.

Judy did hard, hard work also: raising five great kids, a huge job, and tasks such as bringing forty tons of mushroom compost from Pescadero by pick-up truck to fertilize our 318 kiwifruit trees, picking and packing the kiwi fruit, and delivering them to stores and friends.


Whether at Stanford or in your marriage, maintaining two solid bases of support is important. When commentators take potshots at you for being out of the box, your bases, your people, will tell them, “No. That guys okay.”

On arrival here it was evident that the hospital did not fit the usual mode. It was set up to be a space where the class of Nobel caliber scientists who had formed Stanford could pursue world-class research and apply the discoveries to their patients.

My wife Judys mantra was, “Don, you are so far out of the box that you have to remember to keep one foot inside it for support.

As a testament to this guiding principle, my fellow residents and I were taken aside by our Professor Chase and given the mandate, during a beautiful dinner of porterhouse steak: “My sons, your future is in research. Learn molecular biology!”

So I tried that. I pioneered removal of tattoo with Q-switched ruby laser, performed electron microscopy to study the results [5], and devised an instrument, a test, of cognitive knowledge and judgment for residents of plastic surgery in the United States with the help of a Nobel Prize nominee in educational psychology, Professor Lee J. Cronbach, and thirdly, did early work on regeneration of the spinal cord by removing it from the sea of spinal fluid and putting it in contact with cells in tissue. (Little did I know at that time that there were stem cells in that location. I had hardly even heard of stem cells).

I was on my way to the prescribed research goal when something happened. At the beginning of my time at Stanford, my life goals were to have enough money to have a house on a hill, some farm land, private education for my children, a good reputation in the community, to be a leader in plastic surgery, and to be a world expert in some part of the field.

[5] With advice of Nobel Laureate Schawlow, and his co-workers Dick Honey & Art Vassiliadis of S.R.I. (Stanford Research Institute)

There occurred a slip-up in my value system, a system dependent upon tangible income in the form of money. It was simultaneous with a slip-up in Dr. Chases research mandate. Dr. Chase had operated on a 14-year-old boy from Mexico who had come to Stanford with a cleft lip and palate and no money. Because of his deformity, he had had no opportunity for neither social nor educational advancement. Because of his cleft palate, Antonio had great difficulty in communicating. When he attempted to say “Coca Cola,” it came out of his mouth as “Oha Oha.” I assisted in both of his surgical transformations in a minor way.


In two operations with a total time on the operating table of two hours and forty-five minutes, Antonio underwent an instant rehab. He changed from social pariah to complete human personality. Antonio was changed from a dependent person to an independent person and a productive citizen. Fantastic!

Right here at the beginning, this great case lured me. I was faced with a choice: eight years of research to become a world-class researcher with the hope of joining those who were considered eligible for a Nobel, or two years of additional training to be able to derive psychic income from a case like this. I went for the immediate gratification.

In Psychic Income, you become rich with personal satisfaction obtained when you help another person. According to Hippocrates, it accrues when we practice medicine, which is the curing pathology of a medical nature in a single person – one by one.


The interaction of a single persons life, experiencing the cross-section of their life, is a large part of what our lives may be about. Helping their problems in a significant and meaningful way opens the doors. Your life leaps ahead with learning, with joy, and with an addiction to do it again and again, for the rest of your life.

Although biotech executives and research scientists may cure ten thousand or a million with one stroke of invention or a single introduction in chemistry, these professionals do receive Psychic Income. They are at the top of the heap in being able to help. They enjoy a God-like experience. However, they do not experience the joy of successfully treating and learning directly from a single person, which is another powerful motivator. It is only the interaction with another person and that person’s happiness and gratefulness that have a magical power to give the provider a profound happiness, which prompts “I want to do this for the rest of my life.” It is the happiness in the other person that produces the happiness in ourselves. It is not quid pro quo; the object of our action is not for our own happiness, which is only secondary to the happiness in the other person.


Psychic Income is the motor that drives almost every form of altruistic action or service to others. But at a research hospital with very little variety and scarcity of human pathology, the sources of patients were necessarily extramural to Stanford, five hundred miles away. So I started a clinic in Mexico, a mile over the border.

The very first patient that Chase and I saw arriving at that clinic in Mexicali had a bag on his head because of the stigmatization caused by a relatively straightforward burn of his face. I suddenly realized he could be cured by the skills that even I possessed at that early stage of a young plastic surgeons training. All it took was a skin graft and release of the ectropion, and perhaps a little cartilage implant to keep the eyelid up.


I was thrilled to possess the ability to change this patients life. I underwent peak experience at that moment.

The Peak Experience is a sudden coalescence of all previous training and experience into one clear career path. It can be summarized, as “This is what I want to do for the rest of my life!”

Our first goal was hatched, and was realized when Lars Vines and Ernie Kaplan, and later with the help of Steve Schendel, Rod Hentz, and (at that time resident) Jim Chang. Together we started and nurtured Interplast, the Interplast spirit.

We set up a clinic on the U.S. border with Mexico, visiting every three months for patient intake, with twelve operations per weekend, teaching the skills of plastic surgery four times a year to residents, and at the same time, watching them undergo an attitudinal change, that is, learning the value of helping others. It is a way of life that is directly taken from Hippocrates’ directives to us, his progeny. The big vision was that eventually twenty-five percent of plastic surgeons in the world would participate in international humanitarian surgery at some time in their career.[6]

We trained surgeons in psychomotor skills first, followed by behavioral change attitude. This is a reverse teaching method, teaching the skills of surgery first, then cognitive knowledge and body of knowledge, and later judgment and research.

Research goes on all the time. I’ve gone on 159 trips with multidisciplinary teams to perform surgical rehabilitation on cleft lip and palate, burn scars, and hand surgery. We here at Stanford Plastic Surgery have primacy…as the first to bring multidisciplinary teams to developing countries for a single diagnosis. Fifty-eight organizations or medical schools do similar work. We claim primacy as being the first ones chronologically, not necessarily the ones who inspired them to do similar work.


I’m here to tell you that the key to a happy career in surgery is to make room for humanitarian service. As you leave the Stanford bubble, the warm and wonderful and sustaining experience here, I urge each of you to form your own 501©3 foundation, which would have the same objectives as the university: teaching, research an patient care, and community projects.

Your own foundation is a substitute for Stanford, a worthwhile platform by which to carry out the work that you have started here.

There are two types of income: tangible and non-tangible, or Psychic Income. I urge you, young students, not to worry about tangible income; it will take care of itself. But it is to earn Psychic Income that we must act on the service instinct, the side of us that drives us to do things for the benefit of the other person primarily, rather than for the interest of ourselves. This produces happiness in us that is secondary only to the happiness of the other person. It is actually in the oath of Hippocrates, which we have all taken.

The Flexner Report [7] reshaped Hippocratic medicine with the addition of modern research, university education and attention to logical deduction and meticulous observation. All of these Hippocratic principles influenced doctors to be cautious and skeptical. The saying “The art is long; life is short; the occasion fleeting; experience fallacious, and judgment difficult” impeccably summarized Hippocratic doctors’ beliefs.[8] Thousands of years later, we are still under the wings of Hippocrates. Most doctors today choose to swear upon the Hippocratic Oath at graduation. We pledge to treat patients as we would treat our family members; we pledge to work for the patient’s benefit and not for our own, and not to ever be pressured into prescribing treatment that will not best benefit the patient; We also pledge to teach and to share information among the medical community.[9] So, here we are – thousands of years after Hippocrates has left his legacy. Yet the same principles apply to us. This text delineates the principles that glue our medical community together – as teachers and students, as colleagues, and as the future of medicine.

[6]Survey of Memebers of American Society of Plastic and Reconstructive Surgery (1981)

[7]Flexner, Abraham. “Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching.” (1910)

[8]”Hippocratic Medicine.” Science Museum Brought to Life: Exploring the History of Medicine. Web. 28 Jan. 2013.

[9]Greek Medicine – The Hippocratic Oath.” U.S National Library of Medicine. National Institutes of Health, 02 July 2012. Web. 28 Jan. 2013

I have personally witnessed Peak Experience thirty-nine times in my students and residents, who while during surgery, mainly in developing countries, have spontaneously expressed “This is what I want to do for the rest of my life!” or “This is why I became a physician in the first place.”

I urge you to make room in your practice for both tangible income and Psychic Income. “Two roads diverge in a yellow wood.” But you can take them both. Both paths can be followed without neglecting either one. You can follow the road to provide for family prosperity, and it is still possible not to neglect the humanitarian aspect. As many have said, “The money will come.” The key to a satisfactory career is humanitarian service.

A recent study showed that in the United States, seventy percent of physicians are unhappy with their jobs, and forty percent of these would not recommend a medical career, even to themselves if they had the chance again. Contrast this with a hundred percent of those on humanitarian medical missions. They are smiling all the time.

I’ve seen perhaps five thousand slides of my medical colleagues who are on foreign trips – all of the people in all of these slides are smiling. The wealth that derives from Psychic Income is worth more than any material wealth. I am talking about plastic surgery, which is dramatic, permanent, significant, and sustainable.

Teaching is integral to every single action that we take. The recipient in turn teaches another colleague. And this constitutes on even more pure form of service.

As I’ve descried before, a “physician is a professional person who has studied long and hard and who is interested in applying his knowledge primarily to the other.”

My dream is to embed the value of international humanitarian surgery in residents and students, and of course, the faculty already have it. My hope is for us, together, to form a program to produce a balance between world-class research and world-wide patient care. And to include in this program an endowed professorship with annual symposium and awards, multidisciplinary teams in true sustainable collaboration with health care professionals overseas, on a recurrent, scheduled basis, not parachute trips.

With such excellent people and outstanding talent, I believe you will become world-class leaders in international humanitarian programs in medicine.

    It has been an honor to be able to write the sentiments to you. Thank you very much, my dear readers and friends, I love you all.

One thought on “Mobile Surgery: Part II

  1. Don: you found the best parts of plastic surgery long before I wised up. Your example and instructions gave me the tools to follow your path. I am fortunate to have developed a friendship with your old friend, Frank Pilney, MD here in Minneapolis. His mission will continue in Peru. I am fortunate to be part of what he has developed and to enjoy my own part in peak experiences.

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