Prof Paul J Donald has recently stepped down as Chairman of the ORL-HN Department at UC Davis in Sacramento and is winding down to retirement. In this interview with Prof Pat Bradley, Prof Donald explains some of the highlights of his career and offers words of advice to young trainees.
What made you choose medicine as a career?
Around the sixth grade in school I wanted to be a doctor. I grew up in a small, blue collar town in south-western British Columbia in Canada. Less than 10% of my graduating class from high school went to university. This was affirmed after reading AJ Cronin’s book The Citadel. My father was a sawmill operator and my mother a homemaker. They were both interested in classical music; my mother a pianist and my father a flautist and encouraged us boys to play music. To my father’s delight and my mother’s chagrin, I chose the bagpipes. They encouraged us at an early age to further our education at the university level. My two brothers also went to the University of British Columbia (UBC) and both currently work in Vancouver: Keith was an Olympic rower and is an architect, my youngest brother competed in international rugby and became a criminal lawyer and works now as an appellate court judge.
I chose the majors in zoology and biochemistry as they brought me into the courses that were most closely related to medicine. As an undergraduate, I became quite distracted with sports. My grades suffered and in my first application to medical school at my home university I was turned down, because of my lacklustre academic performance. After turning down an opportunity to play professional football, I was fortunate enough to be accepted into the Medical School of the University of Manitoba among a group of four ‘academic long shots’ that the Dean chose. I fortunately did well and was able to transfer back to UBC for my second year and graduated in 1964.
Tell me a little about your military career.
During my first year at UBC my father went bankrupt and became ill. I had no funding other than holiday seasonal work. I also wanted to get married to my fiancée, Roz Keeling, so I joined the Canadian Army, which would subsidise three years of medical school and my year of internship in return for three years of service. We got married in the summer of my sophomore year and had our first child, Scott the following year.
I interned at the Royal Jubilee Hospital in Victoria BC where we had our first girl, Alison and was then posted to a military hospital in Esquimalt for six months, as a general surgery resident. I was then posted to the 2nd Battalion Queens Own Rifles of Canada and spent the next 18 months as a battalion medical officer. This posting improved my squash game and fly fishing skills immensely but did nothing for my medical career. I was then posted back to the Esquimalt hospital where I did a further year of general surgery residency. This period of 18 months in general surgery was of immense importance in the development of my surgical skills and judgment due to the exceptional tutelage of the chief of surgery, Dr Jim Baker. During this period I chose otolaryngology as a specialty and had the good fortune to be accepted into the University of Iowa programme for residency.
Once I was discharged from the Army in 1968 I had to do one more year of general surgery. Thanks to the tremendous experience I had with Dr Baker I was allotted a position ranking just below the chief resident at St Paul’s Hospital in Vancouver BC.
How did the experience with the legendary Dr Brian McCabe influence your career? Were there others who influenced you to seek a career in head and neck / skull base oncology?
In 1969 Roz, our two children and I travelled to Iowa city, to begin my residency in otolaryngology. Under the stern, exacting and stimulating influence of Dr Brian McCabe and his staff, I underwent the most incredibly exciting and fulfilling educational experience of my life. Dr McCabe was the best teacher I have ever been exposed to. Furthermore, his surgical expertise and inventiveness matched his prowess as a teacher. The other faculty member who had a profound influence on me and to whom I owe my interest in pursuing a career in head and neck oncology was Dr Charles Krause. The techniques of reconstructive surgery were taught to me by two outstanding plastic surgeons and intellects, Dr Leslie Bernstein and Dr Januz Bardach. I will always be indebted to these four individuals who helped to shape my career. During this period we had our second daughter, Heather.
What influenced you to go to UC Davis and how did you decide to become involved with skull base surgery?
In 1972 Dr Leslie Bernstein, who was one of my professors began a Department of Otolaryngology at a newly opened medical school at UC Davis in the Sacramento Valley of North Central California. On his invitation I decided that I would be able to do all the various aspects of otolaryngology that I had been trained to do. With a large drawing area, a weak Department of General Surgery and no division of plastic surgery, we had little competition for work. There was a considerable volume of advanced head and neck cancer which was my primary interest. Because of my background in general surgery I began to challenge some of the basic tenets of the limits of surgical resectability, many of which were established by individuals whose experience outside of head and neck surgery was limited. Nowhere was that more apparent than in the situation where a patient had intracranial invasion of a head and neck malignancy especially with attendant dural invasion.
Since my experience in neurosurgery was limited, it became apparent to me that the joint effort of a well trained head and neck surgeon and a courageous neurosurgeon would be necessary to extricate these tumours. Fortunately there were some intrepid souls that preceded me such as Al Ketchum, George Sisson, Tony Cheesman and Victor Schramm who with their neurosurgery colleagues began to perform these combined resections. Those patients without their heroic combined surgical procedures would have otherwise died and moreover, appeared to have reasonable five year tumour-free survival rates. With the support of the Dean of the medical school and the hospital director, I put together one of the first skull base surgery teams in California. Our team was modelled after the highly successful teams of Magit Samii and Wofgang Draf in Hannover, and Victor Schramm and Laligam Shekar in Pittsburg.
What has skull base surgery contributed to the management of head and neck cancer?
I would contend that the innovation of skull base surgery has been the most significant contribution to the survivorship of patients with advanced head and neck cancer in the last half century. This is especially applicable to carcinomas of the paranasal sinuses. Malignancies, for example those of the maxillary sinus with central invasion, with a 15% five year tumour-free survival in prior years, now they have a 50-65% chance of living five years. Any patient with dural and especially brain involvement without skull base surgery were doomed to die within one-to-two years. Even with the modern advances in radiation and chemotherapy I have in my experience with over 250 skull base malignancies only had two survivors who elected these modalities as primary treatment and survived five years.
What have been the most difficult problems for the patients and the surgeons regarding skull base surgery?
The most difficult problems for the surgeon in skull base surgeon are hours of study, dissection and research necessary to prepare oneself to do these complex procedures. The logistics of the necessary equipment, the cooperation with various colleagues who are members of the team and the amount of essential time spent with the patients and family to prepare them for the surgery and the postoperative course are complicated and time consuming.
For the patient; they must be fit enough to endure a long and complicated procedure. Being able to understand the details of the procedure, what their postoperative course is likely to be, and what the nature and severity of the some of the complications they may encounter is a challenge for many patients. Although many of the complications are minimal and/ or remediable, the overall medical and surgical complication rate is around 50%. The rate of cerebrospinal fluid (CSF) leak is low and mostly self limiting but meningitis and brain abscess although infrequent may have serious consequences. For many, the loss of functions such as those imposed by facial numbness and paralysis, difficulty with chewing, loss of olfaction and especially the loss of an eye are very hard to accept.
Although the rate is low, perioperative death is a devastating tragedy for family, friends and surgeons alike. Similarly stroke can be catastrophically incapacitating. Despite the potential downsides of these skull base surgical operations most patients accept the risks and subsequent compromises they may occur and chose surgery and postoperative adjunctive over certain death.
You are a family man, how did you fit in work, travel and family during your career?
The person to whom I owe the greatest depth of thanks for all her years of love and support, through all the years of medical school, internship, Army, residency and which has continued throughout all of my career is my dearest wife of 51 years, Roz. No time was this sacrifice greater than during our years in Iowa. I was never home, and so spent much of my time studying while she and the kids suffered from blistering heat and humidity in the summer and bone-chilling cold in the winter. She endured the early years of my career at UC Davis where I was on first call for three-and-a-half years without complaint. When I received a resident’s call in the middle of the night and discussed a case with him / her then promptly turned the light off and rolled over in bed, she could tell by my body language that I needed to go in to the hospital. I would receive a gentle jab to the ribs and be told that I needed to go in. She was right every time. What has held my life and family together through all this time has been my darling Roz.
One of the things I did was to rise early and hit the office at around 5:30am. A lot of my administrative work and writing was completed during that early morning time period. My family would hold dinner for me till about 7:00pm so we could all eat together. If an attorney wished to consult with me on a case, or a student or resident wished to chat they did so at 6:00am. When I was chief of staff at UCDMC as many meetings as possible were at 5:30 or 6:00am. We always took our vacations together and my wife and kids would accompany me to meetings where and whenever possible.
My eldest son, Scott is a senior partner in a law firm in Sacramento graduating from Cal Western. He was an All-American water polo player in high school and then went on to play for the University of California at Berkley and for a semi-professional team in Melbourne Australia. He is married to Leslie and they have two children; Jackson, 19 who is a sophomore at UC Berkley and is on the rowing team, and Anna 16, who is at St Francis Girls Preparatory School in Sacramento and is a volleyball player.
My eldest daughter, Alison, worked as a fundraiser for the American Cancer Society until her retirement once she had children. Her husband Dan is a venture capitalist and developer in Sacramento and a scratch golfer. Their son Ben, 19 is a sophomore at UC Davis and plays number two on the Varsity Golf Team. Their daughter Lizzy, 16 is also a sophomore at St Francis.
Our youngest daughter Heather is retired from her position as a TV anchor woman in San Francisco. She and Scott have three boys, William 7, Max 4 and Paddy 3.
The youngest son Andy works as a sales manager for a wine and spirits company in Sacramento, and is an avid hunter and fisherman. He and his wife April, who was a scholarship volleyball player in college in Mississippi, produce a cooking magazine, Cooking Wild and they have three children, Piper 5, Lachlan 3 and Hanish 1.
Your son-in-law is not only an otolaryngologist but has chosen the path of head and neck oncologic surgery. How does this make you feel?
I could not be prouder of my son-in-law Scott. He, like myself, had mediocre undergraduate grades. He was an outstanding football player at University and looked destined for the NFL. When he began to court my daughter I found that we were kindred spirits. He saw how enthusiastic I was as an academic otolaryngologist, became interested, took a Masters Degree and graduated in medicine at the top of his class at the University of Tennessee then was accepted for residency and then fellowship at UC Davis. He is a great teacher, an astute clinician, an outstanding surgeon as well as a great husband and father.
What’s it like to spend part of your time in Hawaii?
Roz and I bought two condominiums on Kihei Beach on the island of Maui. We now spend about a third of our time there. It is truly a little slice of heaven. There is seven-and-a-half miles of open beach directly in front of our unit. We walk the beach and swim in the ocean daily. Surf casting and deep sea fishing, kayaking, boogie boarding, body and board surfing, paddle-boarding and snorkelling are all readily available. There are eight golf courses within 10-20 minutes. We have regular visits from family and friends, so we are never lonely.
What are the most significant events and honours that you have received during your career?
The most important award that I have received in my career was the Simon Award. Being part of the panoply of the most notable otolaryngologists and scientists of the last century was a distinct honour. Another significant honour was being awarded the gold medal of the City of Paris by Jack Chirac for my research work on marijuana as an important aetiological factor in the genesis of head and neck cancer in the young. Another important honour was being elected as the first president of the North American Skull Base Society. It has been a great thrill for me to be part of the early group that developed the discipline of skull base surgery.
The greatest thrill of my career was and continues to be the many friends that Roz and I have made due to the extensive travels we have made being a guest speaker in so many countries of the world.
Paul playing the bagpipes.
Who were the most important mentors you had during your career?
The most important mentor in my career was Dr Jim Baker, of the Canadian Armed Forces Medical Corps, who was completely intellectually honest, a compassionate physician, and an incredibly great teacher of surgical skills and judgment. Dr Brian McCabe was a stern mentor but a marvellous educator whose style I have attempted to emulate throughout my career. Drs Gene Myers, Ed Koch, Roger Bowles, and Mansfield Smith have been great supporters throughout the years and have helped greatly in the formation of my career. Although I got to know him more personally during his later years of life I modelled my surgical philosophy on Dr John Conley.
You have published many articles etc. What advice to give young future otolaryngologists, head and neck surgeons?
The most important principle in being able to publish, while at the same time manage a successful academic practice is strict time management. If you get to the office early in the morning prior to the arrival of the support staff you will usually have a couple of uninterrupted hours to write. Attempt to avoid, as much as possible, hospital or medical school committees that involve huge time commitments. Periodically review: all the organisations that you belong to, promises to write articles or book chapters, research projects, extracurricular activities (other than family) and the various boards that you may be involved in, then decide where you can trim these down to free yourself to write. Always bring your laptop to the airport or train station as the waiting and travel times present ideal times to write. Set aside a dedicated day, half day, weekend day or evening each week that is dedicated to writing.
Seek out mentors who will encourage and direct you and even at times review what you have written. If you write an article and it is rejected let it sit for a short time, read the critique, revise and resubmit it to another journal.
If you wish to write on your own experience, wait for enough time to pass after your training before you present it. It is paramount that you be scrupulously honest about results and complications. Don’t try to ‘shine up’ your results. Try to write in an interesting and even entertaining way. Always be precise and definitive and always research thoroughly any aspect of your topic that you are the least bit uncertain of.
As co-editor of Current Opinion how does this fulfil one of your legacies ‘as a teacher’?
One of the great joys of being co-editor of Current Opinion is being able to learn more than I teach. It has been an excellent way to keep abreast of so many of the key issues in the practice and principles of otolaryngology head and neck surgery that I can pass on to our residents, fellows and students. I have thoroughly enjoyed the collegiality of my first co-editor Jack Gluckman and especially so the feisty, unfailingly honest and practical Pat Bradley who is my current co-editor. Working with him has been a delight and always entertaining.
You have always been a ‘great friend to British ENT’. How did this happen?
Any advice to ORL-HNS trainees? Growing up in British Columbia Canada and being part of the British Commonwealth has always created in me a great admiration for the UK. In medical school we used a number of British textbooks and many of my teachers had taken some of their specialty training in the UK. My father’s parents came from Scotland and one of Roz’s grandfathers was from Stoke-on-Trent. We have always had a great interest and affection for the UK. During my early travels I met a host of ENT specialists to whom I instantly bonded with such as Sir Donald Harrison, Tony Cheesman, Arnie Maran, and Alan Gibb. Since then we have made a number of incredibly great friends in the UK who we see frequently several times per year.
My advice to young ENT trainees is the same I give our residents and fellows. Work hard and study hard. First learn the fundamentals of the specialty: anatomy, physiology and pathology. Read and study at least two or three hours a night, five or six days a week. Practise knot tying. Become adept at suturing by practising on pigs’ feet. Understand anatomy and learn surgical dissection by practising on cadaveric specimens. Know the specialty cold and strive to be the best. Do not settle for mediocrity or the ordinary. Be a gunner – your patients expect and deserve it.
Interview conducted by Prof Patrick J Bradley.