In 2002, I was lying face-up supine in the hospital bed in Rome 1068 in U.C. Hospital, San Francisco, with my head scrambled recovering from intravascular CNS lymphoma, and particularly from the third course of chemotherapeutic drugs having a deep profound dream, sleeping away the night with little recent memory but with the past years coming up on the computer screen in my brain clear as crystal.
I awoke at 5:15 am and at this hour a dream was still in my mind. During hypnopompic sleep, which occurs after REM sleep during awakening. It is characterized by wide eyed associations rushing into the mind, principally right brain activity with clear and very acute long term memory, a great time for ideas to pop up, but little memory of the solutions to the problem solved during this time (from wikipedia.org). It was that I was on the hand-surgery service of Dr. Chase and as a young faculty member running the residency-training program. He had asked me to do a “special case.” It was a young male executive with a trigger finger. Dr. Chase introduced us. The patient was tall, husky, and wore a light blue silk suit. Dr. Chase privately had asked that I train the residents and also four new residents on this case.
Lo and behold, the “new” residents were not humans, they were black wolves. But they were “nice” wolves, very intelligent, very nice looking, and had been partially trained already. But they were new to us and new to the four regular human residents.
I felt pressure: the precision necessary for any hand-surgery, the attention required for the training of residents, and the anxiety associated with the training of four wolves to do surgery, much less to have the wolves in the operating room in the first place.
The residents were well prepared as usual, having brought themselves up to date on the rationale for surgery for tenosynovitis trigger finger, the medical alternative treatment, the preoperative work up to evaluate the possible causes of the condition, the possible presence of other clinical conditions which may bear on this patient’s outcome. Their preparation of the operating room was to perfection. Having the equipment and instruments right, the informed consent “administered”, the pre-op lab work evaluated, and the antibiotics already given, we were prepared for anything. We were loaded for any eventually, “armed for bear.”
The residents and I had picked up the patient in my green pick-up truck, which was loaded as usual with mushroom compost. Upon entering the O.R., the wolves were present in this “sacred place.” They were all black wolves, well behaved, and somewhat familiar with the OR politics, S.O.P., and the yellow page but I was worried about their knowledge of sterile technique and anxious as to whether or not I could teach them surgery with their lack of prehensile abilities. But who knows?
Wolves are by far the most sociable of the beasts of prey, but they are not gregarious. The Wolf pairs arid there is evidence that this may be for life. and the male assists the female in caring for the young. As early as four to six weeks is the time for the wolf’s education to begin; they learn by force of example what is necessary to obtain success in life. And the wolf is the shyest of animals. The wolf prior to being hunted by man was unafraid of man, yet restrained by some unknown force from attacking him, very ready by his instinct (a la wild dog) to become his friend, his follower, his helper and his slave.
Arid we by our own instinct were able to understand this trusting bond, as it existed 280 years ago, and were ready to accept our end of this traditional educational arid friendship bargain.
One black wolf weighed over 200 pounds. was intelligent, accommodating, and in walking around the room on its perimeter I collided with the big guy head on; he had his full weight and velocity right into my midsection. The encounter felt not so good.
At that instant, I awoke to the other world and began to wonder what is the meaning of this dream, and how could it make sense. I realized that it was ridiculous to be related to any previous episode, for example, in 1960. I felt it could not have any psychiatric interpretation. I did wonder why I was not allowed to finish the dream. I will ask Dr. Chase why he had such an interest in wolves and why he wanted them to be trained to do surgery. I will ask him why he chose such an aggressive species.
Certain obvious (to me) themes were at intersection. Dr. Chase had a well-developed sense of delegation of authority and responsibility as I, a 32-year-old Chief of Department of Plastic Surgery, was really at resident level, the last year in training.
This young chief’s independence was intermixed with complete dependence on the ace trainees, each one a world class person in process, persons in the sense of their complete development of all of their abilities into skills which had almost no limitation, They were able to figure out how to solve whatever came down the pike. Unforeseen changes, even great changes, were really not a cause of anxiety; they never got to –the stage of saying, “Oh shit, why did I ever get into this?” That attitude never was part of them.
They were stress-seekers all; all nine of us relished the adventure, never having remorse and never experiencing any emotion other than that associated with, for example, a thrilling sporting event.
So it was natural for them to accept the four “Canis occidentalis” as junior partners and following that attitude, the patient himself had no qualms about the service that Dr. Chase provided to the patient through these agents albeit juniors and now albeit other species.
The surgery was predestined to go with success, and the mission of education was also doomed for success because we had incorporated the 3 Cs: Control, Commitment and the ability to Change in midstream with aplomb.
These C-factors have been associated with those high-powered executives who statistically have been shown to have little coronary arterial disease despite living in a sea of anxiety and stress.
The collision in the operating room was not an unusual happening, because it occurs when 15 professionals are all in the same operation room sharing commonality of purpose, but each with individual objectives to accomplish.
And therefore, the affinity of canine and human in this instance was natural because it was deep rooted in the evolution of each of these species and in the mechanism of the dream, this association must have been taken for granted in the primitiveness of the thought process.
The wolf is characterized by confidence, aggression, competitiveness, mental strength, and strength of spirit, cleverness, teamwork ability, valor, courage, survivability—these are identical characteristics to those of the T.K.’s. Therefore Z feel that somehow, these select members of 2 different species were easily able to work together and that they indeed were even useful to each other’s purpose.
As an example of the degree of competitiveness, I remember during the selection of med students for the 6 year residency looking out of a crack in the door of my office as the interviewees were sitting, anxiously talking to the already selected at work second year residents. Oneasked B.K., “How do you become selected?” B.K. told him about all of those tests and then said, “You must write a paper with Dr, Laub as I did. I wrote about the lack of the ability to sweat in certain cleft-lip children, which can cause hyperthermia and death during surgery. And I was selected.” And on and on, he laid it on the poor peer very thick.
Two hours later I received a call from the emergency room to tell me that this candidate was in the emergency room with a bleeding ulcer. Obviously Dr. Lyone was the recipient of excessive and cruel psychological warfare (peer pressure).
The training of residents itself is complex; it is not a simple arrangement between teacher and pupil; it is not a didactic (q.v.) relationship. Rather it is guidance of those who already have the ability to develop and mature their professional skills and their attitudes and idiosyncrasies by themselves – they have the rather awesome set of tools, which they have already developed and they are able to direct by their own free will and under the impact of their more sophisticated professionals in the midst of which they are working. By and large, their elders in this setting go about their own work, their own lives, and the residents and “fellows” act as apprentices, not unlike the apprentices in a guild of the middle ages. For example, a shoemaker would teach the apprentice his trade, the tricks of the trade especially, by which the apprentice would become better than the usual shoemaker or whatever. This is not metamorphosis but rather a shaping. The apprentice pays for the training as they say by service or “in kind” payment by doing servile work, scut work is the jargon word and this is payment to the journeymen and is the incentive by which the teacher is motivated.
But why teach the very secret tricks that distinguish the elite, the number one of 100 others?
Some journeymen perceive little incentive for this teaching, the surgical training of younger colleagues – because the student, the pupil, will become competition if she or he becomes equal or more than equal to the teacher. And the income of the teacher will decrease under fair competition, and will not increase. So is the reasonable mind of many surgeons.
A covenant is signed by the learner by which s/he agrees never to practice within a hundred miles of the great teacher.
No, this is an error in strategy. Rather, why not capitalize on those under you, putting their great and “awesome” abilities to develop to the max—let them grow and thrive in the plowed field that you have prepared so nicely – don’t fence them out with the barbed wire fence; rather, let them roam the wide world of plastic surgery, using your own, almost infinite number of contacts and goodwill for their benefit, to develop them professionally; after all, that is your primary job. These professional learners will return to infuse you and your kingdom with the riches from the provinces, an investment sort of paying off at not 8% interest, but 50-75-up to 150% per annum!
They are you. They are you. They are not other. This is the best system. So in the 5th year of the six year apprenticeship, the residents go off to the “world’s best place” in the particular sub discipline in which they had dedicated their interest, their joy, their objectives and goals.
And along the same line of thinking, the idea is to maximize talent in the selection process. The number one criterion for selection of the residents has become, over years of experience, talent and potential talent. The number two criterion has become what I refer to as “answer #4”.
The criterion, which was previously “answer #3”, was affability and being “a nice person”, even an interesting person, perhaps even a character. This criterion gradually changed from nice person to interesting person, to a character, to a great and grand person, or just one who might potentially be great and grand.
And it soon happened that in the last year of my participation in the selection process, my residents were selected for their incredible abilities and the third criterion had metamorphosed.
After all, if Albert Einstein was knocking on the door, why not take him, even though you would know that a person who was that one-sided (presumably so) would have the character deficiencies in the parts of his personality, which were not as completely developed as his cerebral physicist software. He would certainly cause social, ethical, or other disruptive problems.
But it would be your skill as boss to manage those problems with adroit success. In other words, all problems of those under you are your problems. It would be your self-assumed responsibility to solve them, to anticipate the bumps in the road, and to arrange treatment for them ahead of time. Perhaps you should try to turn the problems into opportunities for the advancement of the system, and the whole process of development of the field.
In the last year of my participation in the resident selection process, I selected according to talent 80%, according to answer number four 15%, according to affability 5%.
Indeed it was interesting, almost challenging, as mentioned previously, because all 50 top candidates scored highest on a 1-10 relative rating in each of the 9 categories.
For example, one of the four residents selected, awesome to the point of scariness, answered my question, “Why did you want to become a plastic surgeon?” not with #4 but with the answer, “Frankly Dr. Laub, I want to have a good lifestyle, be rich, and even famous. I am well prepared.” I was appalled.
I said, “Sandy, you gave the wrong answer! I’m sorry.” And in my mind I drew a red line through his name indicating, “No take, elimination.”
He was not “stopped for long” however. He said to me after I had knocked him down for the count of six, “What is the right answer?” I said, “It is complex, Sandy.” He said, “Come on, please tell me, fill me in on this.” I explained at length, finally saying, “Helping people is the right answer.” He said, “How do I do that? How can I change the answer?”
In two weeks from that day, he was in Mexicali, Mexico at the home of Phil Collins who had given up all earthly possessions to be a community developer. In previous times, he was an athlete doing the 100-yard dash in track and field; he was a stand-up comedian and for some reason he knew every person in Chicago who had an Italian name. He was learning to help people over a 4-week period of time, living like one who had taken the oath of poverty, chastity, and obedience.
On his initial interview, I did not show up because I was doing surgery at a small hospital several hundred yards down the street, a part of Stanford delegated for the plastic surgeons. I had invited Dr. McAninch, visiting professor from University of Oklahoma, showing a special procedure to form a urethra in female to male sex-change surgery.
Linda told Sandy to go over to Hoover Hospital 4 floor and ask to see Dr. Laub in the operating room. Sandy needed directions and advice on how to get there, but he arrived in the operating room and announced, “Bassett, Hopkins, what are you doing?!” The assistant in the operation helping McAninch and myself was Dick Ott, who would become president of the Florida Medical Society, who would form Interplast Florida, and who would direct me in emergency operations for Hurricane Fifi, who hit me sharply in the ribs with his elbow, “Another Jerry Ediz, don’t take him.”
I explained what we were doing and how important this was. Sandy the med student replied, “We at Hopkins have done 8 of these and they don’t work.”
After the case, I set about to test him, “Sandy, Dr. McAninch is now hungry, so take him to one of the best restaurants, buy him a good lunch, here is some money. He likes Bourbon so don’t let his glass ever become dry.” Sandy replied, “Where is a restaurant around here? I’ve never been here.” I gave Sandy the phone book and said, “Look under ‘R’ for Restaurants. And now look down the window into the parking lot there; my car is a 1972 Cadillac Fleetwood which needs some repair, and here’s the key. I’m sure you won’t need to ask any more questions.”
He returned successfully to my dismay. So I asked him to be chauffer that evening, to take us to Embarcadero Center Mexican Restaurant on the 3rd floor, where one of my patients had arranged a special dinner. This was the patient who imported tequila by the tanker, and he diluted it into bottles and sold it for his living. I told Sandy never to exceed 55 miles/hour, and I knew that the speedometer was broken. All seven of us arrived in good shape and Sandy brought us back home in even much finer shape. He knew all the answers, and he was one of the four selected.
Another resident selected was Miguel Calou, who answered with answer #4, “My father is a bishop in the Roman Orthodox Church and has taught me to help people. This is part of my religion and upbringing to become a plastic surgeon so that I may carry out God’s work better.”
He was so nice to my wife Judy that she insisted that he be selected. And when it was time to go to La Ceiba (Honduras) on our 2nd trip, he insisted that he be included because he wanted to learn how to do altruistic work. After rounds, on the first afternoon on the trip, chief resident Dubin asked him to do history and physical on each patient for the next day. Miguel answered, “No, I’m here to improve my skills, to learn how to do difficult operations so that I can become a great surgeon, I will not do scut work.”
Here was the wrong answer from the right type of guy.
I took Miguel aside and explained that doing things for other people, even the chief resident, would get him ahead in the long run and I explained that in so doing, he would lay up “gold coins” in heaven for his own benefit. This tactic may have worked. But Sandy and Miguel were so aggressive that many observers thought that they would kill each other in their attempt to get ahead of the rest of the pack. Behavioral changes were effected, but core values were only modified 25%.
Juana Easton was raised right, and she did right things. She was well trained in the harp, and she did research with the vice-chief of the service. She broke off her wedding arrangements in favor of her professional life after her father had brought the champagne Piper-Heidsieck back from France personally in preparation from that family event. She was well balanced in her life, was an example to all, and was our hero. She came to Stanford as she said, “with balls and brains”.
At her graduation party, at Madalena’s restaurant, the finest French cuisine in Palo Alto, on the second floor in a private room, all four trained-killers enjoyed a great dinner including the last two special courses, which were the bull’s crown jewels frit and calf brain prepared by a special French formula. Nobody could guess which organ they were eating except Juana Easton. We all shared a double Jeroboam of wine from Bordeaux selected by a visiting psychiatry professor.
None of these residents compared with Joe Rosen, who was not aiming to be one of the residents, but to be the best contributor to Plastic Surgery in the entire world. He was so good, in accomplishing every task that he was really frightening. I once asked him to obtain Dr. Vistnes’ slides for me on a weekend, so that I might borrow one. Vistnes is the most fastidious security conscious all things at right angles, O.C.D. doctor, and his slides are in his personal cabinet, it is closed and locked, the office is closed and locked, that wing of the hospital is closed and locked, and it is Sunday morning. I replied, “Joe, there is always a breach in security.” He had the slides by noon, and he even said, “You might make improvements on slide #3 because there have been some new developments recently published on that subject.”
Rosen was to take the severed spinal cord of an accident victim with total paralysis of the legs, to place each individual neuron into one section of a microchip, and the microchip would connect it to each of the distant nerve axons, thus curing the incurable paraplegic condition. He became the favorite of the NASA scientists and of the scientific community, rather instantaneously.
Dr. David Dibbell coined the term “TRAINED-KILLERS”, which is to be taken not in a military or a mafia sense, but rather persons so highly honed in their abilities that they would always and forever get the job done; they could get the letter to Garcia delivered under any circumstances. These were trainees of highest ability and it was 21 years later recovering from chemotherapy that I fell asleep with the thought in mind of these fine associates of mine.
The trained killers, a name recognized by all of our residents in plastic and reconstructive surgery as the effective ones, the ones who not only could but would get the job done, those who were direct descendants metaphorically “hijos de tigre nacieron pintados.” Had they been present during the Spanish-American War, they surely would have been chosen to deliver the Letter to Garcia.
They were able and incredibly reliable, “no questions asked” people whom you would want in your group of four if you were in mission impossible, or in a foxhole in war.
Hippocrates told us that the pupil and the teacher should regard each other as family. Thus, we felt strong emotions relating to the residents. After all, they were chosen from the very top of a pyramidal system nearly unimaginable. The process of elimination was that they were first in primary school, then first or second or third in high school, top in the university class, very high in medical school, complete with success in sports, public service, “politics”, and human relationships, with spiritual-type values, and even emotional development into the seventh layer when rated psychologically one to seven.
And so trained killer as a title is not used without merit. Their motivation to excel was rather awesome. As mentioned, in my last year as full-time chief of Plastic and Reconstructive Surgery (PRS) at Stanford, I proposed selecting the four candidates who were the most distinguished according to these criteria. And thus these four were called by one and all the “TK’s.” It was one of the greatest honors of my career to be associated with them.
We noted characteristics that were desirable by reviewing the selection of the previous years’ candidates. We were interested in the previous years’ successful selection of 48 residents, 6 resident surgeons, 6 fellowship surgeons, 6 foreign scholars of more than two months.
These selectees where at the top of the student achievement pyramid mentioned above, and most had a successful trial internship with us, a month on the clinical service. During this month we evaluated the psychological profile, answering the questions: “Is this a nice person?” (vs. “obnoxious”), “Would you want this person as your daughter or son?”, “Does he or she possess a dental or engineering degree?”, “Are there any sociopathic qualities such as an excessive number of publications – possibly for the sake of the impressive c.v. as a primary motive?”, “Did she live up to her stated reason for becoming a physician and plastic surgeon as stated in the interview?”
4) Rating: A desire to be in the helping profession.
3) Rating: As a desire for self-improvement, e.g. in fine suturing technique, or in an evaluation of aesthetics
2) Rating: As an excellent way to support their wife/husband and children.
1) Rating: As a way to arrive at a fine life style.
They all had passed the psychological testing that we relied on, because we had the good fortune of being trained by the person who devised the test for large corporations and for prominent sport and political figures (Tom Landry, Tony Dorsett, Jimmy Carter).
The evaluation was to help us be “in the other person’s mind” when in crucial negotiations, in order that we might appeal to the other’s value system. Q.V. Selecting the Residents.
The group of four of which I speak all had the rating of seven, the highest level possible in the psychological testing, which had been successfully used for selection of executives in industry and for revealing the value system of those in high positions or in leadership positions in sports).
At the interview day, candidates were also evaluated by our most astute senior faculty. The candidates were checked with the three dimensional special relationship test used by oral surgeons and recommended by our industrial engineering faculty at Stanford. They also did a test for psychomotor skills: placement of small “Indian” beads – each with a tiny hole transferring them onto an upturn needle using surgical forceps, and timed for this exercise. We tested handwriting by an expert in graphology, the secretaries all made their evaluations.
Three letters of recommendation were solicited by each candidate and of course scholastic grades (GPA) were compared as well as the weight of the GPA being given for the difficulty and reputation of the school attended. A short letter about themselves was usually helpful to our selectors.
Astoundingly, these TK’s all scored highest in every test. It was not uncommon to be face to face with the number one student in Dental School, and in Medical School, son of a visible and prominent figure, and of impressive physical features and deportment.
These TK’s made easy work of managing their evaluations. They had not had previous exposure to the test; and they were simply extremely proficient.
They had been proud of the fact that they had come to Stanford with “balls and brains.” And therefore, and of course at their “Swan-Song” Dinner to mark the completion of their six years, we held the celebratory event at the finest French restaurant. My ever-loving wife, Judy, also possessed a TK personality, and after receiving her Letter to Garcia, had gone off to San Jose to Durham Packing Plant to obtain “balls and brains” – bull testicles and steer brains, in order to mark the day by the culinary breadth of the menu. The balls and brains were to be prepared by the finest genuine French chef. These were to be the second and third course after appetizer. The TK’s knew not what. We all sat at a round table in the private second floor dining room. A private messenger came up from the chef. He whispered in my ear “In Frwance, we do not do zis sing.”
I asked the chief chef to use his best French chef book, and perhaps some garlic. The report again came from the kitchen “Is it ok if the special courses come?”
The salad was French and absolutely delicious, but the mystery courses where indeed mysteries, as there was no disclosure, but many guesses. Every organ and part was guessed. But not “B & B,” except for Jane Weston who guessed correctly.
I presented a quad sized bottle of Château Montrose, Guy Tesseron, proprietor, as recommended by Doctor François Bourgeouis, my friend and colleague in Bordeaux, the psychiatrist who had spent a year with me studying GID. To say that we had a great time was a serious miss-understatement. In 1980, we were enjoying “heady” times.