Fogarty: My Pupil and Teacher in Equality

Of the 52 residents, each is distinguished by a unique and individual characteristic. Fogarty has the biggest heart; he was known to take good care of patients. Care which would be classified as the care give by Jesus.   In fact, Fogarty provides us with another order of magnitude in our usual definition of care, in our definition of “doctor” and of physician.  Fogarty’s standards for himself are high and that is an understatement.   In regard to care, Fogarty’s standards are higher than anyone has ever heard, on par with Madre Teresa.  In fact Madre Teresa and Fogarty are the world’s best.  Best in what?  In the service industry, their heart is the BIGGEST, neither are ostentatious, rather they shy from being known for their care.  In a way, they each probably know that if you do good, and somebody knows it, you do not get credit, and perhaps it does not count.  Both of these idyllic characters are nice, both are regular people, both of them do not care about crawling through the manure pile in order to do good for someone.  

Larger than life.

Larger than life, he is.  

I could not have higher admiration for any other role model.  Yet, of course, neither are without E.G.O.  Both realize that everyone needs to be needed and the need must be real.  They realize that they themselves need personal satisfaction, personal recognition, and that they must help improve themselves in order to improve society.  And who says you can’t have fun being a missionary?  He says, “be sure to laugh with them.”

Well, Larger than Life guy came to me by letter.  He stated that he had graduated with honors from the University of West Virginia. graduated with honors University of West Virginia Dental School, and graduated with honors from the University of West Virginia Medical School.  I remember reading the letter written on a regular mechanical typewriter, and not a new one.  He detailed his motivation; he wanted to help people around the world.  

I counted him as being a straightforward person from a minor university with high credentials, which cautioned me to watch for sociopathy.  I invited him to come out for a clerkship.  He stayed one year taking clerkships in many subjects including plastic surgery.  He then came for a second interview.  At the time I asked about his application to Stanford and he repeated he wanted to help people in the world.  I asked if he was living in West Virginia, he said, “No, we rented a home on Hamilton Ave. in Palo Alto.”  I asked how many other programs for which he had applied.  “None other, just yours.”  “How do you know you will get in to this program,” I said.   He reassured me.  I did find out that he had purchased no furniture and they were sleeping on the floor.  “Why?”  He felt he was short of money, but was determined and committed.

I could not understand the breath or the depth of this man.  

He came to the program.  I accepted him because of his answers.  

He appeared, and he paid his dues.  He stayed entirely within the box.   To my observation he did not stray out of the box.  Little did I know that Fogarty had no box to be out of (q.V. Fogarty was the outside of the box).  

Fogarty knew from the onset that he could only affect real change in the world by obeying the rules of the club, or the organization, paying his dues by changing those within the box and respecting all the old farts at least ostensively. ?sp He changed the rules within the box, by changing the box itself and being the best role model.  I don’t think that he ever verbalized this plan.  He may have thought of it, but the plan was obvious to me.  He began to go above and beyond, to do whatever it takes to get the job done and to be friends with the patient.

Fogarty’s characteristics were leading by example, no regard for personal pain, personal cost, personal embarrassment, and pain had no limits. He lived the Letter to Garcia (q.V.).  

Little did I know his wonderful principles of neither of living nor his real psychological profile.  Rather I treated him as a straightforward overachiever from West Virginia with a Dental Degree and wanting to help and never having any negative factors in his file.  

My treatment or management of residents was for me to do everything in my power—which was considerable—to “further the careers of those under me”.  This was my over riding and #1 principle of management.  This was my job.

Sherman Souther expressed interest in microsurgery, he was sent to China with Dr. Buncke, the father of microsurgery  to form a professional relationship with the famed Chinese micro surgeons who had just replanted the amputated first hand.

George Wu expressed interest in head and neck surgery and cleft lip. He was sent to Dr. Bakamjian at Roswell Park Cancer Institute in Bufallo to learn the Bakamjian flap, the new miracle for head and neck reconstruction.  And to Taiwan to Dr. Noordhoff and his hospital for cleft lip and palate reconstruction. ( ?include andto find a Chinese wife)

TRK.  Terry Knapp was encouraged in his career, to be a co-founder of Collagen Corporation during his residency and to pilot the Interplast program in Lo Sotho, Africa as a second year resident.

Mike Dennis founded the Physicians Assistant Program at Stanford by visiting the legislature in Sacramento, changing the laws re the legality of trained medical corpsmen doing yasks heretofore reserved for MD’s,and doing all of the political and medical groundwork for the entire program.

Doug Ousterhout, DDS MD, was Paul Tessier’s, the originator of craniofacial surgery, first fellows.

Fogarty for example, took general surgery in Hawaii under Cliff Straehley, professor from Massachusetts’s General, hand surgery in Louisville under Ralph Kleinert, hand and neck in Roswell Park under Bakamjian, started the international plastic surgery program in Navojoa, Sonora by himself.

Dick Ott did my first latissimus dorsi flap.( under my control, but he was good enouh to perform)

Ron Gruber: it was a joke that he did a rhinoplasty on every patient he had at the V.A. Hospital.

The idea was to push them as hard as they could go.  The idea was to keep their head a little bit underwater, nose and eyes sticking out, but otherwise always under stress to with the goal of maximum education and achievement.  

I asked Fogarty to organize a plastic surgery program in Navojoa, Sonora, to use the Flying Doctors for transportation, to have Bob Bell (q.V. see the interesting story of Bob Bell) our chief pilot to oversee their safety rules of the Flying Doctors and to take as much responsibility as he dared, and he did.  Fogarty made three trips with the Flying Doctors.  On his first trip, the pilot ran out of gas just before landing at San Jose Airport.  On the second trip, the pilot got lost over the Tehachapi Mountains before Bakersfield.  On the third trip, he noted that they flew overweight for that aircraft.  Fogarty and Bob Bell voted to  disengage ourselves from the Flying Doctors and to start our own Interplast Air force.    

The Gift of the Rose Story became famous, one day Fogarty was late for my surgery and was asked, “Why?”  

-He said, “I had to stop on the way in at the florist to order 12 roses for Miss Grant.”  

Ms. Grant was the most beautiful nurse in the E.R.  

“Fogarty!  Giving roses in xxmyxx language used in the Midwest is an actual sexual advance.  Don’t do that!”  

Fogarty merely said, “It’s her birthday.”  

“I’m from the Midwest, and I know what it means.  This a separate language.”  We had a long philosophical discussion, like a little war.  Fogarty won.   I never forgot the incident and when Fogarty graduated from the program and we celebrated at his “swan song party”, I presented him with full public audience, twelve roses, simply to remind him of the event.   He came onstage and accepted them, shook my hand, took the microphone and said, “I would like to present this to Mrs. Laub.”  

During his rotation in Hawaii, Dr. Frank McDowell was his attending.  He was the editor of our national journal on Plastic Surgery and he knew everything, because he was scribe for the world.  He quizzed Fogarty one day on the Operating Room about his favorite method to place a Stienman Pin across the entire mid-face to hold a zygomatic fracture in place.  Fogarty said, “This is only mentioned for historical interest because it is entirely outmoded and doesn’t work to well.”  McDowell responded on this, “Didn’t you read my article? It’s a well known and standard procedure.”  Fogarty argued.

That afternoon I received a phone call from Dr. McDowell.  He said, “You’ve got to fire Fogarty, he knows nothing about facial fractures.”  I tried to defend him a bit by saying, “he is a dentist, he’s done oral surgery and he is not dumb at all, in fact, he is okay.”  McDowell was irate and insisted that Fogarty be censured.  We discussed at length and decided that Fogarty should read one of the sixteen Standard Plastic Surgery Textbooks of McDowell’s choosing each week for sixteen weeks and be quizzed on each every Friday.    

Fogarty acquiesced and “broke his back” carrying out this penance.  He passed with colors.  

Years later, he was to get back at him. When Fogarty was staying at my home, we were to pick up Frank McDowell at the airport on an official visit with me to prepare questions for the American Board of plastic Surgery.  The only vehicle available was my green truck loaded high with horse manure compost to be spread around my kiwi fruit orchard that day.  I didn’t realize the significance of Fogarty jumping out of the car offering to take Dr. McDowell’s suitcases at the curb of the airport.  He then threw them immediately into the pile of  horse manure, got in the car and said, “Laub you have no respect for the important people in plastic surgery.”

When he was with Bakamjian, one of the most civilized persons in the world, Vjaarham was impressed with Fogarty and allowed him to do one of Bakamjian’s first cases under supervision.  It was a radical neck dissection, quite complex and exacting, to be done in a special way that Bakamjian had perfected with his special great invention  delto-pectoral flap.  He handed Fogarty the knife and never uttered a word.  Fogarty bowed, took the knife and within ten minutes became completely lost in the neck anatomy. Bakamjian never said a word, but he very gently and silently took the knife and finished the case never saying any word.  Fogarty was quiet also.  

Several months later, a similar case was to be done with them together again.  Bakamjian gave the knife to Dave, and Fogarty completed the entire dissection and flap without either of them speaking a word.  We are all sure that neither of them ever forgot any detail of that episode.

Fogarty’s photo show of his cases is four carousels long, 320 slides.  The first 24 slides are all magnificent head and neck dissections with the carotid and jugular hanging out, the phrenic nerve identified, and then coverage done beautifully with Bakamjian flaps.

He ends with a huge parotid tumor on an 86 year old who lived in a flophouse downtown on Skid Row.  His reconstruction was beautiful, complete with tarsorrhaphy, Jobe gold weights in the upper eyelid, ability to completely close the eye despite facial paralysis of number 7.  A beautiful case.  Fogarty made house calls on him every other day for two weeks and then weekly for three months.  He died in two years at 88 years of age.

Fogarty said, “If you have any criticism of my cases, blame that on Dr. Hentz, Dr. Laub, and Dr. Jobe. who are my teachers.”

Fogarty gave that lucky patient two happy years and a friendship, which was even more important than the surgery.  

He showed many pectoral muscle flaps used to cover infected sternums after open-heart surgery, a series of eight cases, caused by some sort of infection in the air duct to the operating room.  These were huge and magnificent surgeries, and of course he downplayed his role.

He showed an infected abdominoplasty, done at St. Elsewhere, which had dehisced and was repaired with plastic mesh, which became infected and had to be excised exposing all of the small intestine.  Fogarty swung up a TFL (Tensor Fascio Lata) flap with a lot of muscle attached to provide an abdominal wall.  A wonderful case and that scar wasn’t too bad.

He had a serious of three meningo-myocles covered with latissimus dorsi flaps beautifully.  He later was overseer of their rehabilitation because some had in addition lower limb partial paralysis.  

He did a cross leg flap, of “to be mentioned for historical purposes only”.

An old man with a huge cancer of the entire lower lip.  He excised the entire lower mouth, did Abbe type flap and closed up his oral orifice entirely, he could not eat and was fed by a straw.  Dave later opened his mouth with the same procedures used for microstomia and he looked good.  I was hesitant to ask his age until I saw the good result and the fact that he prolonged his life ten more years with the surgery, from age ninety to one hundred years old.    

He showed a face which appeared to be an acute victim of war.  Dave said, “He’s lucky to have used a rifle on himself and not a shotgun.”  He had several reconstructions and was able to be married and have a job.  He showed an amputated arm, with bone and nerve sticking out in the air, all of the family urged him to try the replant, which he successfully did, but the arm was anesthetic and could not move.  He did a fancy transplant using nerve graft to the brachial plexus and pectoralis major muscle and tendon grafts to move the forearm.  This child was four and a half years old; he had a smile in the picture.

pre op.jpg

postop

 

A young girl was grotesque with a huge hemangioma of the nose.  After spontaneous regression, excision, and reconstruction she looked quite attractive on her marriage picture.  

He showed many breast reconstructions after cancer and a reduction mammoplasty.  The excised specimen weighed fifteen pounds.  The latissimus flap patients, the tissue expander patients, and the tram flap patients all looked great despite Dave vow-ning that he was not a cosmetic surgeon.  

A sarcoma recession of the chest wall and third rib was reconstructed with a latissimus flap and was very acceptable.  

His statistics seemed to indicate that he did five hundred to nine hundred cases per year, and he has been in practice twenty-six years.  He has only had three lawsuits, on one of which he was “bare”.  He was his own attorney after studying up on being a lawyer a little bit.  He quoted some legal terms, I was impressed.  He did not have to pay any money and he was proud of that because it reflected that the patients had a good relationship with him despite a only few untoward results.

His third world experiences emphasized that:

Everyone needs to be needed   

Everyone needs to feel that the need is being met.

The reward is instant and gratifying.

Judit pls place these 3 paragraphs into Manifesto He has been to Peru, and operated on Puno Indians near lake Titicaca.  He is pictured on Macchu Picchu and Lo Sotho.  He showed rosy-cheeked kids from high in the Peruvian Andes and pale hollow faced children from San Pedro Sula and emphasized the difference between 10,000 ft altitude and sea level.  He showed the latissimus flap, the first one done in Ecuador, at Cañar, the one that we did together with the blue-lipped and cyanotic  anesthesiologist Aubrey Maze.

David F. emphasized need to have knowledge of culture differences.  For example, in India, he was careful to make the facial incisions with very little scar because it would prevent young girls from marriage.  There were two twins both syndactyly of the ring and middle finger, which prevented marriage because either could not wear a wedding band. We only could do one more case. And Dave and I solved the dilemma by having them themselves choose Therefore this was not cosmetic surgery, but a socially essential surgery.  We saw a picture of David dickering with a Tibetan up at 12,000 ft arguing about the price of a blanket.  The argument took twenty minutes, David said, “You are an unfair businessman.”  The Tibetan replied, ”You are a capitalist exploiting me.”  They settled on the price of 35 cents.  David took out his money and gave him a one hundred dollar bill to pay.  The Tibetan took out his money change in hand, showing his Seiko watch on the wrist and gold rings, they both laughed and laughed.

He did surgery in Peshawar, Pakistan, where there are six religious factions, each with their own hospital, and the females have separate hospitals from males.  He took a religion course prior to that trip and it was of great help.  He did surgery in Korea at the Leper Colony with Don Mangus. In Azoguez, Ecuador, he developed this program and invited many of the community to stay in his home and go to his schools.  He saw a child with facial burns and the eyelids had become everted exposing the corneas, the condition is a prelude to opacity and blindness.  He took the child with him to West Virginia for urgent surgery.  The burn cases were particularly impressive.  The Russians had dropped toys for the children in Afghanistan, but the toys were really toy bombs, and their hands were burned severely, many into cocoons, which required liberation with skin grafts. The burns to the anterior neck bring the jaw down to the chest, and the child cannot look up at you, not able to breathe under 1st stage of anesthesia. We release this under local anesthesia with ketamine.  He would release the neck and then intubate with endotrachial tube to give the general anesthesia.  His anesthesiologist Bill Ehler is particularly experienced with the procedure.   He had in his case a crescent shaped knife in a silver scabbard for decoration only. At the border any suspicious metal causes immediate incarceration and this is well known in Myamar.

He has been to Guam, China, Bhutan, and to Santa Lucia in the Caribbean five times (doing general practice including abdominal surgery, obstetrics, and treatment of infections).  He’s worried and stressed out because the Lucians now refuse to be referred to Antigua where the regional medical center is.  Of course they prefer Fogarty’s treatment because he keeps them in his house with his children.

In Zambia, he noted 40% HIV positive.  He has done a stable wound to the heart (“easy”).  He has done drainage of subdural hematoma of the brain.  He has improvised Bob Mills’s skullcap out of local industrial metals to hold mashed up facial bones in place.  In Bhutan, he saw six bear maulings in one clinic.  

“Be open to new experiences,” he says.  Never the less, he did not appreciate me placing twelve bottles of tequila under the left front seat in the car he drove across the border from Tijuana to San Diego.  This act increased his anxiety level to crisis levels.  He asked every detail about border crossing.  I told him, “It’s nothing.  They only ask which city you were born in to see if you speak English well.”  When asked in which city he was born by the INS officer, he blurted, “Tequila”.  The border guard laughed and never looked under the seat.  

Fogarty’s present love is coaching every team, basketball, soccer, and baseball.  He claims, “It’s only to carry out soft advertising.  All of my players wear a uniform on which there is imprinted ‘Fogarty’s Girls’ or ‘Fogarty’s Boys.’”  Many patients are attracted to his practice. Apparently the soft advertisement is not perceived as blatant advertisement.  How clever!  But I really think he loves to coach and he is excellent at his inspirational abilities and his technical abilities and his ability as Phil Jackson says, “To get into the minds of the players.”  

Fogarty tells us, “When in a foreign hospital, don’t emphasize the differences between them and our ‘wonderful’ place; but rather emphasize the common aspects, e.g. ‘they don’t have many materials available, but they try just as hard as anybody and are perhaps more devoted to their work than we are.’”  

“Foreign professional friendships, teach the people and you won’t need to spend money on bricks and mortar.”

“These people are the same as us.  In fact everyone in the world is really the same.”

“If you plant for a year, plant wheat seeds; if you plant for ten years, plant fruit trees; if you plant for a hundred years from professional friendships and educate the people.”

Fogarty is happy 95% of the time.  It is reported that 92% of Americans do not like their job.  Mihaly has shown us in Flow (2000 pts reviewed in the Book of Psychology) that happiness is in the process, not the attainment, in doing something we have never accomplished and using the fullest concentration.  A climber just before he attains the 2,000 ft cliff, the baseball player just before hitting the third homerun in one game, the scientist about to discover the cure for AIDS after studying 15 years. “Happiness occurs the day before Christmas, not at the actual Christmas experience” (Mihaly).

Fogarty is in the process of Flow, he lives life to the fullest and is in the process of solving the unsolvable, attaining what we would never expect and he will have more surprises in store for us before you have read this story.   

 

EPILOGUE

 

As noted above, I made an estimate of Fogarty’s ability and character on 3 occasions: first in response to his letter of inquiry describing himself, second after the first interview, and on the post residency interview.  As noted above, I underestimated him on all three occasions.  On these occasions and of course on many others, I’ve learned that I seriously underestimated him, but this lack of a sense of entitlement only served to push him a bit, because he knew my feeling toward him by instinct.  He was allowed to be liberated, to run free, and to fly like an eagle.  He is a truly great person, and we in the late 20th century and early 21st century have been lucky to have him and be able to benefit from his contributions.

He has touched 100,000 people. These people will in turn be in contact with millions.  

As for us, where my underestimate is concerned; I am sure at this time that he actually desired to be underestimated.  I have heard him say many times, before we would go into a meeting, or before beginning a project, or in reporting about an encounter, “Let’s go in one-under.”  I now realize what one-under is:  it is to allow the other person to underestimate so that he is not able to be accurately analyzed and put in a category. He will never be placed accurately into someone else’s plans and objectives. He is then in a position to perform his own pre-planned objectives with his own methodology.  I’ve tried out this Fogarty method on occasions at meetings, but until now have not known the power of that mindset.

And of course in any transaction, both persons are affected, not the one.  The winner always pays a price for having the other “lose”.  More input than expected gets absorbed into the dominant one’s cerebral cortex and fund of experience.  The “winner” is affected just as surely as if Fogarty were using the “fifth column”.  Let’s all use The Fogarty Method a little bit.

Thank you Fogarty, you are truly a great person for this world.  May your DNA live on for centuries.    
       

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