E46 Nobel Prize Winners In Surgery With David Feliciano

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do. Today we have the absolute pleasure of welcoming back Dr. David Feliciano to Cold Steel. Many of you know Dr. Feliciano or DVF, or simply the boss as he’s known in most of the United States trauma community. Among many of Dr. Feliciano’s talents is his near encyclopedic knowledge of surgical history. As a former trainee, I can personally attest to that it extends well beyond trauma and vascular surgery. Today we’ve asked him on the podcast for a special topic, which is to talk about different surgeons that have won Nobel Prizes. This is particularly topical as our own Michael Houghton from the University of Alberta just won the Nobel Prize last week for his paradigm shifting work on hepatitis C. Although we’ve linked Dr. Feliciano’s paper outlining surgeon Nobel laureates to the show notes at the bottom of this podcast, we thought we’d take a moment before the podcast begins to summarize each of them in case you don’t have time to review it. The first and arguably most important surgeon Nobel laureate was Theodor Kocher. Yes, that’s the same Kocher as the kocher incision and the kocher clamp. He was born in Switzerland, his 1909 Nobel Prize was awarded for work on physiology, pathology, and surgery of the thyroid gland. We must keep in mind in particular, the state of American and global surgery at that time was quite different than what we see today. The second winner was Allvar Gullstrand. He was born in Sweden. He was an ophthalmologist. And he won his Nobel Prize in 1911 for his work on the die optics of the eye. The third winner, perhaps my most famous winner, is Alexis Carrel. Alexis Carrel, was born in France. Although he did spend a reasonable amount of time in Montreal, Canada. He developed a lot of his Nobel Prize winning content with a gentleman by the name of Guthrie, as well as Dakin’s who you hear Dr. Feliciano mentioned a little bit in the podcast as well. The fourth winner was Dr. Barany from Vienna, who essentially was an EMT physician and surgeon who won his Nobel Prize in 1914 for the physiology and pathology of the vestibular apparatus in the middle ear. Perhaps most famous on the Canadian front is Frederick Banting. He was born in Allison, Ontario, Canada, studied at the University of Toronto, as many of us know, and was also an infant infantry men in the Canadian Army. His work was highly influenced by Dr. Best, who again was left out of the Nobel Prize quotation. Banting won his Nobel Prize in 1923 for the discovery of insulin. Interestingly, and sadly, he died in the crash of a military plane in 1941. The sixth winner is Alexander Fleming from Scotland. He won in 1945 for the discovery of penicillin of all things. The seventh winner was Walter Hess of Switzerland, who was also an ophthalmologist. But in reality is he switched his careers to more neurosciences and when won the Nobel Prize in 1949, for functional organization of the inter brain. The eighth winner was Forssmann from Berlin, Germany. In 1956, he won his Nobel Prize for heart catheterization and pathologic changes in the circulatory system. Another Canadian was winner number nine, Charles B. Huggins, who is from Nova Scotia, Canada, and is in fact a urologist. He won in 1966 for the hormonal treatment of prostate cancer. Finally, and arguably most famously is Joseph E. Murray as the 10th winner. He is a plastic surgeon by training. He was born in Massachusetts and really quite importantly, he won his Nobel Prize for both organ and cell transplantation and the treatment of a number of human diseases. Our conversation with Dr. Feliciano surrounding Dr. Murray is our particular favorite. Dr. Feliciano, if we if we start at the beginning then my understanding was that Kocher was the first of surgeons to win a Nobel Prize in 1909.

David Feliciano  05:23

Yeah, actually, there are total of 10 right now who have won a prize since the very beginning.

Chad Ball  05:30

Oh well!

David Feliciano  05:31

Kocher won his in 1909. And I can read from his certificate. Nobel Prize certificate says for his work on the physiology, pathology and surgery of the thyroid gland. His obvious contributions were improving the mortality, the operation, recognizing the hazards of taking out the parathyroids. And also of basically creating mix edema after a total thyroidectomy. If you read his early papers, you know there was a substantial mortality when he first started his career in the 30% range with a routine thyroidectomy. This dropped really under 2% by the time he ended his career.

Chad Ball  06:25

Well, one of the things that comes up over and over again, Dr. Feliciano with regard to not only Kocher, but you know, clearly Alexis Carrel and a number of other folks, is there their technical mastery. How do you? How much weight do you put into that? And also, how do you think that impacted their tremendous careers from the laureate side of things?

David Feliciano  06:50

You know, people, the surgeons who have won the Nobel award, have often not been practicing surgeons, many of them did their work in the lab. For example, Carrel never passed his exams in France to go on the faculty at the University of Lyon. And that’s how we ended up first in Canada, and then in the United States at the University of Chicago. And other than his work in the laboratory, with CC Guthrie at the University of Chicago and later at the Rockefeller Center. His work was really in laboratory animals, tissue culture, things like that. It is of interest, however, that his particular interest in vascular repair, as everybody knows, was prompted by an assassination attempt on the president of France in which there was a stab wound of the portal vein. And the individual, the president died from exsanguination. And even though Carrel at the time was only a student, he questions his professor in France on why couldn’t they just fix the darn thing. And this prompted a lot of his later work with Guthrie at the University of Chicago, in which, you know, they published nearly 30 papers and somewhere between a year and a half and two years, and the list of contributions is incredible. Another example is Fleming, the originator the discoverer of the Penicillium mold, who passed all of his exams for the Royal College of Surgeons in England, but never practiced surgery and simply went into a lab at the university. Because that was evidently his prime interest. Charles Huggins, spent a career in urology at the University of Chicago, because his chairman told him, that’s what he should practice. But really many of his contributions were in the hormonal treatment of cancer with oophorectomies and orchiectomies. And his Nobel is not for any technical feat, but simply because the amount of time he spent looking at the endocrine effect on certain cancers. So it’s a varied group of people with a varied group of interests. And many of them were clinical surgeons, and many of course, were not. So it just goes to show that surgeons can be a very good surgeon scientists and contribute immensely.

Chad Ball  09:39

In your experience, and with your knowledge, which one of these folks would you say essentially balanced the clinical side with the researcher basic science side the best, would that have been Kocher?

David Feliciano  09:55

Um, that’s a fair question. You know, again, his contributions to lowering the mortality after thyroidectomy are legendary. And you know, this came after something like 5000 thyroidectomies at the University of Bern in Switzerland. So in his case, there was little question that volume and experience contributed to better results. I would say one of the best examples of a surgeon scientists, was really the most recent Nobel Prize winner as a surgeon that would be the late Joe Murray from Brigham and Women’s Hospital now. I mean, this man was trained as a plastic surgeon, had tremendous experience after World War Two working on veterans. And then when he got to what was Peter Bent Brigham back in the day, and he needed to work on transplant, which really wasn’t even especially at the time. And as everybody knows, there was no immunosuppression when they did their first transplant. So from the very beginning, they recognize they would have to have a technically perfect operation between identical twins. But later on, when immunosuppression came, you know, Murray made just continuous contributions to transplant, you know, first in the monozygotic twins and later in dizygotic twins, then in unrelated donors, then with the use of immunosuppression. And again, this is a man who’s trained as a plastic surgeon. The apocryphal story is that when he was doing grafting of burned military personnel, after World War Two, he could not predict why some skin grafts were taken so well and others were rejected. And he suspected there was an issue with the immune system. But originally, they had to just perfect a new operation, how to do it, how to preserve the organ that was coming in as best they could. And it was only later that they got involved very heavily in immunosuppression. I met Dr. Murray, very impressive, incredibly tall man, very humble. And we wrote a paper, a biography about him some years ago, and I think it was the Archives of Surgery. And one day, my secretary in Atlanta said to me, do you know a Dr. Murray? And I said, where’s he from? And she said, Boston. And I said, you mean Joseph Murray, the Nobel Prize winner? And she said, I guess so. But he was very nice on the phone. And it turned out that he had read our paper and was so enthralled with this. It’s his own biography, by the way that he wanted extra copies for his family, which we readily sent to. So very impressive, man. Needless to say,

Chad Ball  13:10

Yeah, he’s a fascinating guy. And, you know, for so many reasons. The very nature of the content of of transplantation. And what he was studying is particularly interesting, because of course, if you look at the early 60s, the concept of biological incompatibilities was I think, the term that they used, and it was sort of seen as almost a lost cause until some of these advancements that he was involved with, came after. Tremendous.

David Feliciano  13:36

Excuse me, I think people forget that they did the first several transplants in monozygotic twins since they had no immunosuppression. And it was only later as they started to get some drugs available that they could move on eventually to unrelated donors. It’s a great story. There are a lot of people involved. Certainly, Frany Moore deserve some credit, the long term chief of surgery at the Brigham for sort of encouraging these efforts for directing Murray, obviously a very bright and experienced guy into the field, for bringing in local nephrologist, to sort of monitor the activities. This was really a team effort, Murray got the Nobel Prize. But there was always a question about whether Frany Moore should have received some credit though he did not do the original operation, though he did carry the kidney from one operating room to another. But again, Murray is one of the people who impresses me the most, because after he gave up his transplant work as the field became more developed, he really became one of the world’s most famous cranial facial surgeons. And for a period of time, you know, they invited Paul Tessier over from France, to work at the Brigham, and advanced the field of cranial facial surgery, with these two giants working together. So again, contributions in many areas, and not surprising in light of his particular contribution to transplant.

Chad Ball  15:28

Wow, that’s a fascinating story. Well, one of the winners, that laureates that sort of interests me almost for the opposite reasons is António Moniz. Moniz I’m probably saying it incorrectly but, you know, really credited with essentially the modern lobotomy and the the concept of trying to introduce psychosurgery. And it seems like, like that particular Nobel Prize was, was essentially an aberration. The other thing I think that’s really interesting is if you look at the number of nominations that some of these surgeons had, you know, he had, I think it was 18 or 19 nominations, over about a 30 to 35 year period, if you look at, you know, Alexis Carrel, he only had one, Kocher had I think six or seven. But it’s it seems like maybe, unless I’m missing something a Nobel Prize, kind of gone sideways. And maybe in retrospect, is is not quite what it seemed to be at the time.

David Feliciano  16:26

I, you know, one of the backstories with a Nobel’s is that, usually, you’ll get it after you die. So people start campaigning early, when these major contributions are made. It’s interesting Moniz received his Nobel Prize, at the same time as Walter Hess. Hess basically, was head of the department of physiology at the University of Zurich, but got really interested for unclear reasons in the diencephalon, which I had to look up before I wrote in on paper. It is the inner brain connecting cerebral hemispheres, he spent 25 years in the field and received the Nobel in 1949. And the two of them both Hess and Moniz were awarded Nobels for their study of the functional organization of the inter brain as a coordinator of the activities of the internal organs. So but again, there are a lot of backstories with the Nobel, there have been some egregious overlooking of people who clearly made major contributions to certain areas that for which another was awarded the Nobel Prize. There have been individuals who have received the prize within days after they died. But the long term contribution is really part of it, where it’s contribution that stays in the public eye, if you will, and count and people do campaign for them. And it’s interesting, the number of times that individuals have been left out from the Nobel Prize. So there’s an entire book written about Alexis Carrel, and Charles Guthrie at the University of Chicago because Carrel was later in his career at the Rockefeller Institute in New York. All sorts of contributions again, with tissue culture, development of a sort of a cardiopulmonary bypass circuit with Charles Lindbergh, the aviator. I mean, this is a man who was in the, the public and scientific eye for many years. Whereas Guthrie was simply a MD, PhD, who spent his years in the lab but many people forget that it was Guthrie who suggested when he and Carrel were working together, that if they simply incorporated the intima into all their bites in vascular anastomosis that the risk of thrombosis would decrease tremendously. And that had really been one of the problems is the way they were suturing blood vessels together in the lab at the time, was to put their sutures outside of the enema, and even Carrel admitted later that it was Guthrie suggestion, excuse me, that they incorporate all layers of the arterial wall. By doing by doing that they were able to do end-to-end anastomosis, end-to-side anastomosis, aortic patches, like the branches for thoracoabdominal, renal transplants, putting the head of one dog onto the head of another, taking off the hind limb of a dog and then putting it back on. I mean, I laugh sometimes when I listen to vascular surgeons because they act like they’ve invented everything since 1950. But really in 1905 in 1906, almost everything we know technically about vascular surgery, for example, again, the triangulation technique came from the whole physiological laboratory at the University of Chicago, with Guthrie and Carrel working together. But again, Guthrie did not did not receive the Nobel Prize. And there’s an entire book written about this by the Midwestern Vascular Society who long felt that Guthrie had been left out for reasons that are never clear. It’s just hard to know why people would not understand when there are two people’s names on every paper, they would probably be working together and contributing equally. One of the other most egregious ones was the discovery of insulin. There’s not an entire book written on the history of this. But the people who were left out, were, of course, the medical student who worked for the summer with Frederick Banting, Charles Best, and then the visiting biochemist, James Collip who helped refine insulin itself. And only a Banting and John McLeod, in whose lab they were working over the summer, were awarded the Nobel Prize. And if you read the book, it really shows that at least, all four of those people made some contribution to the discovery of insulin, though again, only two, of course, received the Nobel.

Chad Ball  22:03

Yeah, the the politics of it are so interesting. And of course, with Banting being a Canadian from I think he’s from Alliston, Ontario, Canada, you know, yeah, we we hear a lot about him. And again, as a graduate of University of Toronto, his name is on a lot of stuff and certainly the the slight or the the ignoring of of Best is talked about a lot. The other Canadian I guess, to be nationalist, a little bit on the podcast here, I think was was Huggins. I think Huggins was a was a Nova Scotian.

David Feliciano  22:39

That’s correct, yeah, born in Nova Scotia, but went to medical school at Harvard, and completed his training in general surgery at the University of Michigan. When he went on faculty, as I mentioned previously, the chair of surgery at Chicago at that time was the legendary Dallas Phemister who was chair there for a long time. And he recommended that for whatever reason that Huggins go into urology, and he eventually established a laboratory for cancer research where he made many of the contributions regarding effect of hormones on cancer, particularly cancer of the prostate, and cancer of the breast. And then he had a variety of other contributions during his career, he, he was really a true scientist as well.

Ameer Farooq  23:40

One of the interesting things that you write about, in your paper of about Nobel Prize winners in surgery is sort of the complicated history and background behind some of these surgeons, like, for example, I think we’ve been talking a lot about Alexis Carrel. And one of the things you bring up in your paper is sort of his leanings towards Naziism and authoritarian regimes. How do you think about that complicated history from a person who’s, you know, really one of our surgical greats? And, you know, sort of the complicated nature of of our heroes.

David Feliciano  24:19

You know, it’s interesting that he received his Nobel many, many years before his sort of liaison with the Vichy France regime. And I think, however, it has really clouded his legacy. As most people know, there are many people in France historically, who after the war, felt he was a collaborator. I, you know, I’ve read at least two books on this, and it’s not clear that he was a collaborator. What he wanted from the Nazis was money to establish this institute of man. But the reason I got interested in in him was that when he died, he left all his widow left all of his papers, to my medical school, Georgetown University in Washington DC. Because one of the chairs there who was a mentor of mine when I was a student, Charles Hufnagel, met him and befriended him after the war. And so naturally, because of the connection to my school, I did read a bit about him. Obviously, very controversial figure, but again, his Nobel Prize, far preceded all of his political stuff. If you want to read some interesting surgical history, I can recommend one or two books on Carrel, because he was obviously a brilliant guy, made tremendous contributions in various areas of science, as I mentioned, and every time I’m on rounds, Chad can probably tell you that if anybody mentions Dakin’s solution, I go into a long dissertation on who Dakin was, and what was his connection to Carrel, particularly if I hear it called Carrel solution, because of course, Dakin was the biochemist who joined him in France during World War One, sent over by the Rockefeller Center to figure out if there was a chemical that they could use to prevent all the soft tissue infections. And of course, that chemical is diluted Clorox, as we all know.

Chad Ball  26:48

It’s interesting Boss, to contemplate, I think, where were these 10 folks are from, where they were born and where they were raised. Do you sense any pattern in either the countries or the regions or the educational systems or the pathways in any of these folks? Or are they really 10 separate train tracks so to speak?

David Feliciano  27:11

I’ve never thought about it Chad. I’m just looking at the paper and Kocher was from Switzerland. Gullstrand in ophthalmology was from Sweden. Carrel was from France. Barany was from Austria. Fleming, of course, was from Scotland. No real pattern, just, I guess, reflecting the history of the development of surgery and science being in Europe, you can see that all of these early winners were really Europeans. And it wasn’t until Huggins and then Murray much, much later that Americans were involved. Now, certainly in other specialties, Americans have really dominated the Nobel Prize in Medicine and physiology, for many years, but in surgery, not shocking that it came much, much later than all the early prizes that went to European surgeons.

Chad Ball  28:18

If If asking maybe a tough question Dr. Feliciano, I don’t know. But who would you think is still alive now or, or, or would come to the front of your mind about, you know, who should be in the running or consideration for a Nobel Prize at this point in surgery. And in particular, I realize, you know, your long history with Dr. DeBakey, both as a trainee and as a as a colleague and a partner in in Houston. And I certainly recognize that he’s not not with us anymore. But what’s your sense of someone like that, for example, would would he be, in theory, a reasonable candidate? Or was that you know, not even close  or where do you where do you frame him and others?

David Feliciano  29:05

Yeah, I’m no expert on this. But without question, his volume of contributions in vascular and cardiac surgery would make him an obvious candidate. I think the issue is was there one single contribution that changed the field. There, there’s some controversy about his invention of the roller pump, whether he borrowed some idea there or or just worked with an engineer who had the idea, but that would be, you know, a mechanical thing but of course, it allowed for cardiopulmonary bypass, his willingness to use synthetic materials for grafts with the apocryphal story that he sowed the grafts together front and back on his wife sewing machine. So yes, I think he would be, would have been considered a candidate. But I just suspect that there was no single contribution that stood out so much. That didn’t also involve many other people. The individual who’s who has struck me for a long time as being left out, was the late Tom Starzl work in hepatic transplantation. Now, I’m blanking on the name of the English surgeon who was also involved who I believe is still alive. But if you go back and look and read about these original operations for hepatic transplantation, one, there was a technical tour de force when you think about it, you know, they were talking about 12 and 15 hour operations in the beginning. One of my favorite memories in my career is I was on a panel at the American College of Surgeons Clinical Congress in Chicago, and it was on liver. So there were transplant and trauma and elective hepatic resection and Starzl was on the panel. And about halfway through the panel, after we gave our talks Starzl stood up and said into the microphone, I have to leave now. They’re in the middle of a transplant in Pittsburgh, and I have to get back to help them finish. This, of course, we were all in Chicago. So these, these operations took a long time. But but if you go back and read some of his science, before he did the transplant about the direction of flow and the SMV, and in the splenic, and so called apoptotic factor. And again, the technical problems, which still occasionally befuddle hepatic transplanters. This, this man really pushed this idea. And certainly he was one of the few, excuse me, at the time, who really had the scientific background, the brilliance this man was a former Markle scholar, and the leadership capability to drive this such that, you know, Pittsburgh remains one of the premier transplant centers in the world for all sorts of transplants, you know, not just the liver, but the small bowel, the heart, lung, etc. So I always thought that he had been overlooked and I wasn’t sure why maybe it was not considered to be as quite an important a first as the kidney transplant that Murray did. But clearly, this is a transplant that saves a lot of lives. It’s not easy to do. The technical and scientific aspects came from Starzl. So he’s one.

Chad Ball  33:13

Yeah, it’s it’s interesting to reflect on him in particular, not just because of, you know, our biases, I guess, of loving the liver. But, you know, in visiting Groote Schuur Hospital where Christiaan Barnard did the first cardiac transplanting in Capetown. There’s a very clear and strong link in a lot of the commentary and a lot of the evidence there that, you know, he still not everything, but certainly pieces of what he eventually did from Starzl also, you’re exactly right. He’s contributed in so many ways.

David Feliciano  33:44

Yeah, like it gets a little blurry. I mean, I’ve written a paper about cardiac transplant in my youth. And you know, there were a fair number of people including Richard Lauer at Medical College of Virginia, now, Virginia Commonwealth. David Hume was the chairman of the department at the time. And Hume, of course, was instrumental in the later development of kidney transplant. My mentor, Charles Hufnagel, transplanted a kidney to a patient’s arm at the Brigham. And whether the kidney ever made any urine was never clear. And I even asked him before he died. So there you know, there are a lot of people involved in these these major developments, it’s a team effort in in one center, and then there are competing centers, who are also making contributions.

Ameer Farooq  34:43

One of the things that I love about hearing you talk about this is just clearly your encyclopedic kind of knowledge about the history of surgery, not just just general surgery, but obviously also the cardiac surgery and transplantation in all these myriad fields, and, you know, I’m struck by how important that knowledge of kind of the history of where we’ve been, and how that informs where we are today is so important and and perhaps is maybe a bit of a vanishing lore of knowledge, like why do you think it’s so important for young surgeons to have a sense of the history of where surgery has come from? And why did you what what was the motivation really to even write this paper about Nobel Prize winners?

David Feliciano  35:35

Well, first of all, answer the latter question. There’s a famous sports commentator in America, whose name I will not reveal. But he wrote a book, on sports. And somewhere casually, in the book, he mentioned that there were, I can no longer remember exactly that there were either two or three surgeons who had won the Nobel Prize. Now I’m no class A surgical historian, but I knew he was wrong. And so I started to look up and you simply go to the Nobel site, and you can start recognizing the names. And then if you do a little further research there, there are people who before me, as you know, wrote some very detailed papers on all the surgeon winners of the Nobel Prize. So it was simply curiosity in the beginning with this particular project, where I really thought that a somebody made an error in their book, by the way, I wrote to this individual, and reminded him that there were many more surgeons than he realized, but I never received a response. And to answer your first question, it seems to me if you’re going to be a surgeon, it’s not a job. It’s not just a trade, it’s a profession. And so I’ve always been interested in sort of the whole gamut of intellectual activities that surround the field of surgery. And I’m in my office here at home. And I’ve got two or three shelves of surgical biographies, historic surgical books, and it just became something I was very interested in. So that when somebody wrote a book, like when Tom Starzl, wrote his sort of history of transplant, in the book, Puzzle People, meaning he could put people back together, you know, I bought it right away, I sent it to him, I got it autographed. I mean, I just think, you know, recognizing the incredible contributions that others have made, in other fields of surgery be beyond trauma should be recognized. Just one apocryphal story. When I, I asked the residents at Emory one time, the senior residents, why don’t you know more about surgical history, trying to prompt them to read, you know, some of the books that I’ve mentioned. And the response I got was not we’re going to run to the bookstore and buy every book on surgical history. The response was, well, why don’t you teach us a course and you teach us about surgical history. And that response really deflated me? Because again, it’s, you know, part of the question of what exactly is surgery, and it’s, it’s much bigger than a day job, it’s something you can really immerse yourself in, intellectually in many, many different ways.

Chad Ball  38:46

You know, it’s intriguing Boss that I brought this up in our in our first podcast that we did, but one of the greatest gifts you gave me as, as your fellow was to come to you the ability to come to you with a with a research project, or an idea or a question that starts with why isn’t this like this? Or can we do this with that? And your, your ability to put that into a 150 year history of why that was a good idea, or why that was not a good idea or how it had been tried again, was something that you know, you know, I’ll thank you until the day I die, but in particular, it has framed a lot of the things you’re talking about, it’s framed the entire way I look at the field at the profession. So I just have to have to thank you for that. You know, I try my best to impart that on on some of our trainees in Calgary.

David Feliciano  39:41

You know, it’s, it’s, it’s really interesting to me, that trauma as a field was was one of the last to really develop scientifically. You know, we’ve kind of fiddled around with shock since Walter Cannon and we still haven’t figured out how to bring people back when their pH is 6.8 or 6.9. And one of several failures in academic surgery during my 42 year career. And one of them for sure is that we have not done studies, in many areas of surgery, where we don’t have clear cut answers. The cancer surgeons with their cancer groups are far ahead of us in outcomes and results of therapy. And it’s really only in the past, you know, I don’t know two decades, that we’ve started to do some decent studies, excuse it’s always given is that, you know, we’re in a clinical arena. All patients react differently. A variety of therapies work, therapy changes over time. So it’s hard to compare results one decade with that the previous decade. But I to me, it just, it just shows an intellectual weakness. I’m not a scientist, but I’ve always been disappointed that my really bright colleagues were really busy doing meta analyses would do, I wish they would do better studies from the very beginning, you know, big multicenter studies and not the national trauma data bank, which doesn’t have the granularity to solve very many problems, to great epidemiologic resource. But, again, that’s a failure and trauma. And I think it came about because we were so busy trying new therapies very quickly to see if we could save lives. And it’s only in recent years that we’ve really done some decent comparative work. But I can think probably any, I think all three of us who put our heads together for half an hour, could probably think about 30 to 50 different surgical problems for which we do not have a good answer. And that disappoints me.

Chad Ball  42:10

Yeah, that’s a that’s a great point. One of the things I wonder that maybe plays into that, and certainly not as an excuse, but how do you perceive like, what when I look across these 10, folks and what they won their Nobel Prize for, how do you perceive the increasing number of hurdles that we all experience as surgeons or surgeon scientists or simply scientists in our university setting, certainly North America to try and get some of this work done. I mean, to think about the pathway to liver transplantation in 2020, it’s almost impossible to believe that that would happen now. And you know, I wouldn’t say killing the innovation, but certainly stifling or slowing innovation is something that that I think I see more and more and more of and certainly feel like I experienced what what are your thoughts on that?

David Feliciano  43:04

No, I agree completely. I just to do a chart review, at any university these days means you have to go through an institutional review board, even when the patients are unidentifiable. There, there have been a number of editorials in the past couple of years about the particular problem of IRB’s, where, you know, patient security, patient confidentiality, and all have risen to the forefront. I think we all understand that. None of us wants our medical information released in any identifiable way. But you’re absolutely right. I have a feeling that many of the contributions made by Nobel Prize winners would never have been able to occur in the modern era. And do I think this emphasis on confidentiality and HIPAA and what not is stifling some studies? Of course it is. There’s probably a happy balance here. But it’s a little bit like the 80-hour work week, you know, the minute you get the politicians involved and give them a crusade in a field they know nothing about they’re going to muck it up. And I do think that’s part of what’s happened here. Every study that we talk about, amongst the fellows at the shock trauma center, we always put in this factor, like how long will it take to get through the IRB? How long will it take to get the medical records released? How long will it take to get our forms approved by the universe? I mean, it’s just incredible. And it’s hard to know if it’ll ever go back but uh, you know, I’m I’m it’s wonderful that we’re able to do meta analysis based on hopefully some decent studies, but it just would be great to really answer questions with good prospective randomized studies. And and certainly in a lot of areas, it’s never going to happen.

Ameer Farooq  45:18

I was curious if you had some resources for the aspiring young resident who is interested in surgical history? What are your your top favorite books or papers that you would recommend trainees to check out?

David Feliciano  45:36

Well, the one I’d start with, honestly, is Surgery: An Illustrated History by Ira Rutkow you know, Ira was a surgeon, and basically takes you through world history and certain epics, identifies all the major players, talks about their contributions. And it’s not a hard read, it’s a, it’s really almost like an atlas of surgical history. And if you start with that, you’ll get a lot of names that might intrigue you. The other thing I think is worthwhile is to buy surgical biographies by people who have been prominent in the field and, you know, sort of find out how they found their way how they made their contributions. One of the other books I really recommend to have on your shelf is the famous book by Majors, which is a collection of the early reprints on diseases has, have you ever read Grave’s paper on Grave’s disease? Well, Major’s book has all the original papers. And you can read about the six original women, you know, all of whom had to had a recent emotional episode in life, a divorce, death of a parent, illness of a child, and how they suddenly developed hyperthyroidism. And you know, there’s a book which is not just about surgery, but does include surgical problems. And then I have some other generic history of surgery books that are available. It’s just a question of taking the time, you know, forcing yourself to read five to 10 pages a night, and then getting interested in some of the sub areas of information, and pursuing. I just give you one example, I was very curious on how every textbook I read said that if you had a rib fracture, you lost 125 mls of blood. And I, of course, was one of those people who repeated that in various articles. And one day, I said, My God, where’d this come from? And I traced it back almost a century, and could never find your original source of this. We recently wrote a paper on hard and soft signs in vascular trauma. And one of our former fellows, Anna Romagnoli, who’s up at the Mass General doing vascular training, call me one day and said where are the hard and soft signs come from? And I kind of confabulated an answer but she went back and finally traced it to one or two papers. So once you find an area that intrigues you, it’s worthwhile to go back and find out the history.

Ameer Farooq  48:45

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