(UroToday.com) The Society of Urologic Oncology (SUO) 2021 annual meeting in Orlando, FL hosted the 2nd Annual Joseph A. Smith Jr. Mentorship lecture with this year’s recipient being Dr. Patrick C. Walsh, MD, University Distinguished Service Professor Emeritus at The James Buchanan Brady Urological Institute at Johns Hopkins Medicine.
Dr. Walsh began his honorary talk by thanking Dr. Jeffrey Holzbeierlein for this great honor and highlighted that everyone in the room is a mentor. Faculty mentor trainees and trainees mentor one another, and often the faculty as well. He went on to acknowledge Dr. Smith for his lifetime of contributions and devotion to the spirit of mentorship in the field of urologic oncology. He stressed that he hopes that the people in the audience would find something in his talk that will be helpful in their own roles as mentors.
“Why do I deserve this honor? I was just doing my job”. In 1915, the Brady residency was instituted by Dr. Hugh Hampton Young, modeled after the Halsted surgical residency, and designed to train future leaders in the field. Subsequently, Dr. William Wallace Scott perpetuated that tradition during his tenure from 1946 to 1974. When Dr. Walsh succeeded him in 1974, he felt that this was his most important job. Because these trainees would be responsible for the future of the urologic field, his emphasis as a mentor was to inspire them to make discoveries. This was the reason for “Discovery” as the title of his presentation.
Dr. Walsh went on to emphasize that he did not do this alone and put up images of faculty mentors between 1974 and 2004 (see image below).
To be a successful mentor, it is critical to have talented, devoted trainees. Dr. Walsh shared an image of the 2018 reunion of faculty and residents from 1974 to 2004. Over those 30 years, 62 residents were recruited, 87% went into academic medicine and 22 went on to chair major academic departments.
Dr. Walsh went on to address the question: “Why did they come to Hopkins to train?” Dr. Walsh believes that they often took credit for the quality of their residents because they feel they selected them. However, the reality, in his opinion, is that the program only offered them the position. It is the students/residents who selected them instead. Dr. Walsh went on to share a personal story regarding one of his previous trainees, Dr. Mark Gonzalgo, a former Brady resident who is currently Vice-Chair and Professor at the University of Miami Miller School of Medicine. Dr. Walsh had asked him recently why he came to Brady for his training. Dr. Gonzalgo responded by saying that he was enamored with the idea of training at Brady after watching “The Operation” on The Learning Channel, which was a show featuring an operation, the patient, and the surgeon. During one episode, Dr. Walsh was featured performing radical prostatectomy. In Dr. Gonzalgo’s mind, that was the place to be and the surgeon he wanted to be model his career after.
Dr. Walsh next re-emphasized that Discovery was his and others' number one priority. Every resident and member of the faculty had a focused area of opportunity - in the laboratory, clinic, and operating room. Fifty percent of their space, funds, and effort were devoted to discovery with the remaining fifty percent devoted to clinical operations. Residents were treated like graduate students, expected to identify their interests early in their training and eventually know more about the subjects than any faculty member - and to make new discoveries. How does one make an important discovery? Three excellent quotes come to mind:
- “If you want to make an important discovery, pick an important problem” - Dan Nathans
- Do one thing well before you do the next thing. “Less is more” - Mies Van der Rohe
- Don’t work on the current most popular problem. “Go to where the puck is going to be” - Wayne Gretzky
But how does one find an important problem that no one else is working on? Dr. Walsh believes that the key lies in listening to your patients. If they ask you a question for which you cannot find the answer or tell you something that sounds incorrect, then this may be your opportunity for discovery. As Albert Einstein once said, “The ones who follow the crowd will usually go no further than the crowd. The ones who walk alone are likely to find themselves in places no one has ever been before”. Thus, Dr. Walsh chose to walk alone.
He went on to share his discovery of nerve-sparing radical prostatectomy. In 1977, soon after developing the technique for controlling bleeding from the dorsal vein, a 58-year-old man returned three months postoperatively and informed Dr. Walsh that he was potent. As trivial as this may sound nowadays, this was very noteworthy at that time as all men were impotent following surgery. Everyone had believed that the cavernous nerves ran through the prostate. However, from this one case, Dr. Walsh knew that this was not true. But where were the nerves? He knew the answer was not in any anatomy book. No one knew and no one was looking for them. This was his opportunity to walk alone. He went on to share the changes in prostatic anatomy illustrations in Campbell’s Urology between 1979 (4th Edition) and 1992 (6th Edition). At the time of the 4th Edition in 1979, only seven percent of men with prostate cancer were undergoing surgery. As a result of these anatomic discoveries and the advent of prostate-specific antigen (PSA) screening, this number rose to 75% of men in their 50s and 50% of men in their 60s by 1992.
Next, came his interest in hereditary prostate cancer. In the late 1980s, Dr. Walsh saw a 49-year-old man with prostate cancer who asked him an important question that he could not answer, “Is prostate cancer hereditary?”. The patient’s father, three paternal uncles, and grandfather had all died of prostate cancer. Dr. Walsh was unable to answer his question because at that time family history was not a known risk factor. This initiated a journey of over three decades working on this problem.
Dr. Walsh went on to detail notable discoveries in the operating room, clinic, and laboratory at Brady between 1974 and 2004.
- Operating room discoveries:
- Robert Jeffs/John Gearhart: functional reconstruction of bladder exstrophy
- Fray Marshall/Bruce Reitz: excision of renal cell carcinoma involving the right atrium; hypothermia and cardiac arrest
- Lou Kavoussi/Lloyd Ratner: laparoscopic living donor nephrectomy
- Patrick Walsh: Nerve-sparing radical prostatectomy
- Clinic discoveries:
- Alan Partin: Nomogram for predicting pathologic stage
- Charles Pound: Nomogram to predict the natural history of biochemical failure after radical prostatectomy
- Ballentine Carter: Longitudinal evaluation of PSA using PSA kinetics to improve diagnosis and prognosis
- Jonathan Epstein: Characterization of criteria for cancers that are ideal for surveillance only
- Laboratory discoveries:
- Leper: Mapping alpha-1 adrenergic receptors in benign prostatic hyperplasia (BPH)
- Burnett/Snyder: Role of nitric oxide in erectile function
- John Isaacs: Translation of basic science theory into clinical trials for lethal prostate cancer
- William Isaacs: Discovery of the genetic basis of hereditary prostate cancer
Dr. Walsh’s advice to trainees was to:
- Make a difference with your life - consider devoting it to discovery.
- Listen to your patients - they may help you find the answer to questions you didn’t know that you didn’t know.
- “If you cannot find the answers, consider asking the Almighty for help. That’s what I did.”
- The most important requirement to be successful is a partner in life who embraces and inspires your dreams and is willing to accept the sacrifices that will be necessary. He went on to pay tribute to his devoting wife, Peg, who in his words, made these dreams come true.
Dr. Walsh went on to pay tribute to his mentors that molded his career. He started off by recognizing Dr. Francis D. Moore, who was Moseley Professor of Surgery at Harvard and Surgeon in Chief, Peter Bent Brigham Hospital. Dr. Walsh graduated from Case Western Reserve University School of medicine in 1964 and went to the Peter Bent Brigham Hospital. He applied to the Brigham because the initial training consisted of two years of adult surgery and one year of pediatric surgery at the Boston’s Children Hospital and was a notable center of excellence. In 1962, two years prior, Dr. Joseph Murray, a future Nobel Prize winner for transplantation, performed the world’s first successful unrelated cadaveric kidney transplant. The following year in 1963, Dr. Moore had his famous photograph taken on the cover of Time Magazine.
Dr. Walsh went on to describe The Peter Bent Brigham Hospital as a small jewel and reflected fondly on his experience over there working with a “big family”. After finishing his internship in 1965 at the age of 27, he went to see Dr. Moore for advice about where to train in Urology. The following was his response: “I suggest that you train with Willard Goodwin at UCLA, spend a couple of years doing research at a center of excellence, and return here to succeed Dr. Harrison as the Chief of Urology and the Elliott Carr Cutler Professor od Surgery at Harvard.”
In his own words, Dr. Walsh stated that he had no idea that he was even worthy to enter academic medicine, much less to be a leader. While he had little faith in himself at the time, he had to trust that Dr. Moore’s words were correct. He proceeded to train at UCLA where his clinical experience was excellent. He was, however, still concerned about the need to make an important discovery in the laboratory, which he perceived to be a prerequisite to justify an appointment at the Brigham. He then proceeded to spend the second year of residency in the laboratory. Needing guidance with a research topic, he wrote to Dr. Moore asking for advice, essentially asking “where’s the puck going to be?”. He wrote back: “You should work on the endocrine soil in which prostate cancer grows.”. A brilliant suggestion. The answer was molecular endocrinology and the timing was ideal. Four months after starting his laboratory year, Dr. Jean Wilson published his seminal work on the intranuclear binding of dihydrotestosterone (DHT). At that time, antiandrogens were new and no one knew how they worked. The findings of this paper suggested they either blocked the production of DHT or its binding to the receptor.
Eighteen months later, Dr. Walsh presented his paper “Mechanism of Androgenic Action: Effect of Specific Intracellular Inhibitors” at the American Urologic Association Meeting. This was the first time most urologists had learned about the molecular action of androgens. He also proceeded to work on other important problems:
- The first proof that antiandrogens blocked the effect of adrenal androgens on prostate growth
- Feedback regulation of gonadotropins in men - effect of estrogen
In 1971, Dr. Walsh finished his urologic residency, and from 1971 to 1973, he fulfilled his military commitment as a staff urologist at the San Diego Naval Hospital. Between 1973 and 1974, he worked as a visiting assistant professor of medicine at the University of Texas Southwestern in Dallas, TX working with Dr. Jean Wilson. During that time, they described the 5-alpha reductase deficiency syndrome and induced BPH in young dogs demonstrating androgen/estrogen synergism. At last, nine years after that memorable meeting with Dr. Moore, Dr. Walsh felt that he had the necessary credentials. On July 1st, 1974, he assumed his role as Professor and Director of the Brady Urological Institute.
As it turned out, Dr. Walsh ended up at Hopkins rather than the Brigham, but Dr. Moore continued to be his mentor for many years. This experience left an impact on him as a mentor and he learned the importance of seeing talent in others that they did not see in themselves. Because of his own personal experience, when he saw young people with extraordinary promise, he would pull them aside, explain to them their unique talents, and offer them the support they needed to reach their fullest potential.
Dr. Walsh ended his talk by thanking the SUO for this mentorship award and stressed that he accepts this award on behalf of all the outstanding Brady faculty who inspired residents to pursue discovery. And again, none of this would have been possible without the support of mentors such as Dr. Moore.
Presented by: Patrick C. Walsh, MD, University Distinguished Service Professor Emeritus, The James Buchanan Brady Urological Institute, Johns Hopkins Medicine, Baltimore, MD
Written by: Rashid Sayyid, MD, MSc – Urology Chief Resident, Augusta University/Medical College of Georgia, @rksayyid on Twitter during the 2021 Society of Urologic Oncology (SUO) Winter Annual Meeting, Orlando, FL, Wed, Dec 1 – Fri, Dec 3, 2021.