Jeffrey Spiro: Okay, this is
January 25th 2004. This is the American Head and Neck Society interview with Dr. Ronald
Spiro. I’m Dr. Jeffrey Spiro conducting the interview in Dr. Spiro’s home in New Rochelle. So I guess what we’re going to do is follow the script here, which I don’t actually have, so I’m going to borrow. We can certainly digress if we need to. And I guess the first question that we decided to ask was who or what actually got you interested in medicine to begin with?
Ronald Spiro: Well medicine was a late decision to me. Actually I was well on my way to a career in engineering when my mother asked whether I was interested in medicine. Now I had always been interested, but money was a problem and I never thought they had the ability to pay for medical school. When she heard I was interested, she said: “You do it and we’ll support you,” which is how it happened.
JS: Interesting. So then you went through medical school obviously and were thinking about career choices. I guess the next thing we were asking all of our interviewees was what actually influenced you towards the field of head and neck surgery itself?
RS: That was a rather intriguing situation. What had happened was that I had gotten a deferment under the Berry Plan, which allowed me to finish four years of general surgery after medical school. At that point, I had a military obligation and ended up with the Air Force in Morocco for two years. It was difficult to set up a practice from several thousand miles away, so I decided to get some additional training in surgical oncology. We can talk later about how that happened. My general surgery training was at the Bronx VA, which was a program that was strong on practical experience. Why the Bronx VA? Well at that point, my wife, who had been supporting us, was ill and the Bronx VA offered what seemed then like a huge annual salary of $2500 per year. So I backed out of a confirmed residency slot in the surgical program at Mt. Sinai Hospital and went to the Bronx VA, which did not make the people at Mr. Sinai very happy. During my four years in the VA residency, I met an interesting guy who became a real role model. He’s the one I owe a debt of gratitude to for directing me towards oncology and head and neck surgery in particular. John Lucas is a name that’s not going to ring loud and clear to most head and neck people, but he’s the one who co-authored (with Edgar Frazell) what was then the definitive article on squamous tongue cancer. John had a very well-defined interest in head and neck problems, but as it happened, his appointment at Memorial was on the breast service. In order to stay involved in head and neck surgery, he would come to the Bronx VA and take residents through head and neck procedures. After my first case with him, all I could think was, “Wow, wasn’t this fantastic?” His operative style and his whole approach were new to me. To cut to the end of the story, when it became evident that I was going to have to go overseas for two years and that I would be interested in additional training, he suggested a senior residency in surgical oncology at Memorial. So John Lucas inspired me, and also conspired to help me get the job.
JS: They didn’t call it a fellowship at the time? It was called a senior residency?
RS: It was called a senior residency involving two years of rotation through all of the. surgical services. I had finished my general surgery training in 1960, followed by two years in Morocco serving as an Air Force surgeon until mid 1962. From 1962 until early 1965, I was a senior resident in surgical oncology at Memorial and spent 6 months on the head and neck service. In those days, young general surgeons were interested in the program mostly because they wanted the intensive exposure to head and neck surgery. Things have certainly changed in these times, but that was the attraction then. Anyway, what happened is that within a week of discharge from the Air Force, I was in Sloan Kettering working. I started directly on the head and neck service, which not supposed to happen. Ordinarily, you were supposed to rotate through all of the other services, with the head and neck service saved for last when you knew your way around. That’s not what happened with me. Edgar Frazell was the chief at that time and I went directly on his private service. Some of you may recall the name Jerome J. DeCass, who was the other resident on service at the time, and later became the Chief of Surgery at NY Hospital. He was in his second year of his senior residency and graciously followed me around during the first week. In reality, he was only following specific directions from Edgar Frazell to “watch this guy Spiro. I don’t know who he is or what he is, and I don’t want him to get lost.” So he was just faithfully following instructions.
JS: I guess this kind of leads into our next question, which we had proposed, which was asking if there was anyone whom you would identify as a mentor to you early in your career. I don’t know if you would include Dr. Frazell in that list or not.
RS: No one stands out particularly: Frank Gerald, Edgar Frazell, Hollon Farr, Randy Tollefsen, Charly Harold were all role models. There were very few surgeons like them in those days, with their huge head and neck surgical experience. I was never exposed to Hays Martin when he was chief since I arrived several years after he retired, but I’m told that he always let everyone have his say at weekly conference. He would speak only after the others had finished, and then his last sentence would be: “The responsible attending will make the decision”. It was a very democratic service in that respect. Edgar Frazell also had the last word, and. again, everyone made his own decision. The intriguing thing was that management decisions were remarkably consistent, which I guess was a tribute to the power and personality of Hays Martin.
JS: So there really was I guess a “Memorial Way” of doing things.
RS: For sure there was!
JS: Which I guess would lead into the next question, which would be, what was the practice of head and neck surgery like when you first started? What was the “Memorial Way” back in the early to mid-60s?
RS:I think the axiom that would apply is that bigger was better. Certainly the extensive procedures were more glamorous. And it was just around that time that the epitome of aggressiveness was published, which was Oliver Moore’s paper on simultaneous bilateral radical neck dissection with sacrifice of both internal jugular veins. To get the timeframe straight, this paper was published in 1964, and I finished my training in 1965. Looking back on it, I believe it marks the end of the aggressive era.
JS: Sort of the high point or the low point.
RS: However you look at it. But suddenly there was awareness that this was not an experience ever to be duplicated and that future therapeutic efforts would have to strike a better balance between results and morbidity and mortality. It just wasn’t going to be acceptable.
JS: So I guess the next thing that we have listed – was there anyone else who had a strong influence on your career? We could just say anybody. Would you identify anybody in particular who was the most important in shaping your career?
RS: Well here is where we can now back off a little bit. The situation in 1965 was that I finished somewhere in April and started a solo private practice in Manhattan, I rented space in none other than the office that had been set up by Hays Martin and which was being used primarily at that point by Randy Tollefsen. He had taken over the lease from Hays Martin. The deal was that Hays Martin kept the prime consultation area in the rear of the office for his exclusive use in exchange for referring any new patients requiring surgery to Tolly.. Even though I had never had exposure to Hays Martin in his prime, I may have spent more time chewing the fat with the old gentleman than anybody he had trained. When I finished seeing my patients, he would usually be back there with nothing much to do. I would join him and we’d talk about this and that, head and neck and otherwise. He was a remarkable personality. Eventually, this allowed me to get involved with him as a co-author. I remember one episode in particular. His literary talents were formidable, but he was certainly not known for brevity. In this instance, he had written a very lengthy paper on radiation-induced skin cancer, including an impressive collection of illustrative cases. There was nothing like it in the literature. The first half of this paper consisted of a lengthy diatribe against radiation oncologists, who in those days often used radiation for benign conditions. The second part was an analysis of his fascinating collection of patients with radiation-induced skin cancer. He showed me the manuscript, and was obviously upset that it had been rejected by several journals because it was too long. Dr. Martin acknowledged that one editor has suggested that maybe there were actually two papers in the manuscript. With that suggestion in mind, yours truly had the temerity to suggest that the paper should be divided into two. I assume surgeons are aware that Hays Martin was triple boarded: general surgery, plastic surgery and radiation oncology. He was unique in that respect! So the idea was that he had put together this marvelous history of radiation oncology that should be one paper, and then the second paper should be a workup of the entity called radiation-induced skin cancer, mostly carcinomas but also other mesotherial-type tumors. He looked at me, shook his head and said, “Okay, you do that.” I took the paper, chopped it in half, set aside everything that related to the history of radiation oncology and then edited the second half of the paper very aggressively. I had a fair amount of journalism experience, so this was not a problem. But I hadn’t quite prepared myself for the reception that I received when I handed it to Hays Martin, because I can assure that you nobody had ever dealt with one of his manuscripts that way. He read it, thought about it for a while and finally said, “Oh, alright, we’ll submit it,” but he was not a happy camper and I believe our relationship was never quite the same after that.
JS: Did it get accepted?
RS: Yes! Elliot Strong was the third author. I believe it was a landmark paper in its day. There was nothing in the literature to match the number and variety of cases that he had collected.
JS: Are there any other particularly memorable experiences not even necessarily from those formative years but from your career in general that you wanted to share with us?
RS: Nothing that comes to mind at the moment, other than the travails of solo private practice in Manhattan. This was from ’65 to ’72, at which point Elliot Strong, who had taken over Edgar Frazell’s job, made an offer that I found hard to refuse – to come onboard the head and neck service full-time. And I should respond to the question previously asked: “When did you get involved in head and neck?” Initially, my solo private practice involved the treatment of head, neck, breast and soft tissue tumors, which was the typical New York City surgical oncology practice in those days. My exclusive commitment to head and neck came when I opted to join the head and neck service at Memorial.
JS: And that was 1972?
JS: I guess this next question is probably pretty easy for you given the time span of your career, which was how the field of practice of head and neck surgery and oncology has changed over the years.
RS: It’s important to get a sense of what head and neck surgical practice was like in the 60’s and ‘70s. There was an adversarial relationship with radiation oncology and with otolaryngology. At Mt. Sinai, which was where I did my surgical oncology during my 7 years in solo practice, my privileges were limited. Even though I was probably one of the best-trained head and neck surgeons on the staff, I was not allowed to perform a laryngectomy if it was for a primary in the larynx. It was OK for me to resect a larynx only if the primary was in the basic of the tongue or the pharynx, extending to the larynx. In fact, there were often people perched outside of the operating room door to see to it that I didn’t violate any of the ground rules. Radiation oncology was a constant fight. They wanted control of the patients. None of the ecumenicism that developed in the ‘80s was apparent.
JS: There wasn’t a lot of combined therapy then. It was either/or.
RS: That’s right, it was either/or, and the concept of joining forces and both doing a better job for the patient was totally alien. So they were very hostile days, with a lot of scratching and clawing going on.
JS: And the head and neck surgery itself I think also has changed a lot over those years.
RS: Yes, head and neck has changed enormously since then. I recall that when I was in training and it was imp0ortant to get a view of the nasopharynx, the use of the original nasopharyngoscope, with its then tiny field of view, was a real frustration. We would ask a more senior member of the staff to have a look, but I suspected that he wasn’t seeing much more than we were. Of the several new developments in the 80s and the 90s, nothing was more important than the introduction of instrumentation which allowed better patient evaluation. And then the CAT-Scanner came on the scene. I well remember the crude assessment provided by sinus tomograms. We would embark on a maxillectomy with a very limited sense of tumor extent. Results are much better today largely because we know more precisely where the tumor is and we also know better ways of doing it when the tumor extends beyond the scope of a traditional maxilectomy.
JS: And we’ve also gotten more conservative in some areas as well.
RS: That’s very true! You may recall that my Hayes Martin lecture at the 1993 meeting Society of Head and Neck Surgeons was entitled, “Less Can Mean More.” We began to mature and understand that a more tailored, less radical procedure, sometimes combined with radiation therapy and later chemotherapy, could yield similar, or even better results with less disfigurement and dysfunction.
JS: It’s probably very hard for the young folks in the field to be able to relate to the ‘60s and the early ‘70s – very different time. I guess the next question is, keeping that in mind, what do you think has changed the least over all of that time?
RS:First, let me come back to one of the things that has changed the most. I have to give the plastic surgeons their due. It’s important to realize that in the ‘60s and ‘70s, if I needed a reconstruction, only three people were available when I had a major reconstructive problem: me, myself, and I. Very few plastic surgeons then knew more than I did about head and neck reconstruction. This was a reflection of their inexperience rather than of any particular talent on my part. With the introduction of new flap techniques, regional tissue transposition, and finally microvascular repair, the millennium has arrived. We have reached a point where the head and neck surgeon can perform virtually any ablation knowing that it will be possible to put the patient back together. There’s a picture of an Andy Gump patient that’s shown in national meetings and in some of the old textbooks that some of you may have seen. I don’t know how it got there, but it happens to be a man that Jerry DeCosse and I double-teamed in 1962. Frank Gerold was the attending surgeon, waving his Yankauer suction like an orchestra conductor from the head of the table as we performed simultaneous bilateral radical neck dissection with tongue, floor of mouth and total mandible resection. Surprisingly, that man got a lot of mileage. He required some additional surgery and radiation and survived in a sheltered environment for years. Needless to say, that kind of surgery is no longer appropriate or necessary.
JS: So what’s the constant in the background though? All of these many, many things have changed. What’s still the same?
RS: What’s still the same? Well, certain standard procedures are still necessary at times. Radical neck has a place, even though some make it sound like a procedure of last resort. I think it’s important for young head and neck surgeons to know how to do a good, conventional radical neck dissection when that’s the correct procedure to do. There’s still a place for composite resections and one need not be embarrassed, or feel that you’re being archaic in doing them when indicated. What I’m saying is that there’s still a place for radicality, but only under much better-defined circumstances.
JS: The next thing we had on the list was, what do you think has been your most valuable contribution to the field?
RS: That’s an interesting question. I believe I made a significant contribution to the management of salivary gland tumors by updating and reporting the Memorial Hospital experience. Basically, I added many important details to the landmark paper on salivary gland carcinoma published by Foote and Frazell in the 50’s. In particular, I devised the first staging system for parotid gland carcinoma, and focused attention on clinical staging as the single most-important prognostic factor. I pointed out that staging also largely determines treatment. Other contributions that I also feel good about are my papers on mandibular swing and median labiomandibular glossotomy. The ideas were certainly not mine originally, but I would like to think that I helped popularize these procedures. I believe they are still used today in carefully selected situations because surgeons read about our experience and decided to give them a try.
JS: Okay, my next two questions go side by side. We can ask them together. What do you consider the biggest current threat and on the other hand the biggest opportunity in the field of head and neck surgery right now?
RS: I think the biggest threat is the attempt to substitute gimmickry for solid judgment and experience. There’s a tendency, for example, to rely too much on imaging. As I have said before, imaging has certainly changed the whole field of head and neck surgery and allowed surgeons to ascertain tumor extent with accuracy that couldn’t be approached before. On the other hand, nothing turns me off more than someone who throws up a CAT-Scan or an MR and says, “This is inoperable.” Such a judgment will usually be correct, but there are certainly times when imaging can be misleading. My concern is that some patients may be denied a chance of cure without first-hand, intraoperative assessment. Resectability can sometimes only be determined by starting an operation and proceeding in a way that doesn’t burn bridges, allowing you to back out if gross, complete tumor removal is not possible. I think this is the approach that gives the patient the benefit of any doubts that may exist.
JS: So are there any big opportunities for head and neck surgery right now? It’s hard to spot, I guess.
RS: Head and neck surgery seems to be in “decline” at this time. Even if that’s not exactly the right word, it’s not far from the truth. It has a lot to do with the climate of contemporary surgical practice, with third-party interference and with certain attitudes and expectations within the community at large. I think there are many talented young people who are not going into head and neck surgery because of inequities in reimbursement. That bodes ill for the specialty in the future because we really need bright people exploring new avenues.
JS: I guess with that in mind, are there any particular words of wisdom that you would convey to the current and I guess even the future generation of head and neck surgeons or oncologists, if you will?
RS: Beware of advice from grey-haired retirees. It’s still a wonderful and challenging field. It generates anxieties that are unique in the sense that all too often the head and neck surgeon is faced with a decision that requires true grit. Consider the young patient with advanced disease who may need a disabling or disfiguring procedure that will change his life forever. You’ve got to have the wisdom to know when that kind of surgery is indicated, and the courage to see it through under very stressful circumstances.
JS: Alright, well thank you very much for your time on behalf of the Head and Neck Society. We appreciate this opportunity and we hope to be seeing you still in the future. I guess we’ll call it a wrap.