Jeffrey Spiro: This is Jeffrey Spiro interviewing Dr. Elliot Strong at his home in Pelham, New York. First I want to thank you, Dr. Strong for participating in this project on behalf of the Society. I’m going to follow the script, although we can certainly digress, therefore my first question would be where or what or when or how did you actually get interested in medicine to begin with?
Elliot Strong: I always was interested in medicine and can’t remember ever having been seriously considering any other career opportunity. I was the first one in my own family to go to college, to say nothing about post-graduate school. I don’t know really what influenced me to make that decision as a less-than-teenager, as a matter of fact.
JS: I can relate to that, because I felt the same way, but I know where that came from. It was my own family experience. But there were no physicians in your family.
ES: No, no physicians. I had one cousin who was a nurse trained at the Brigham Hospital. She probably, although not closely associated with me, was of some influence in directing my career thoughts.
JS: So you were in medical school. I guess you had decided on a surgical career. What pointed you towards head and neck surgery in particular?
ES: Actually, when I went to medical school I wanted to be a general practitioner. And as I got further into medicine it became obvious that in order to be a good general practitioner, you had to have an encyclopedic knowledge of everything in medicine, and it was increasingly apparent that that was not going to happen. So I became more interested in surgery and went through thoughts of being a gynecologist or a general surgeon. But during my surgical residency program I had the opportunity to rotate for a year to Memorial Hospital as a resident.
JS: Do you remember what year that would have been? Late ‘50s?
ES: That was in my third year in surgical training, so that would have been 1959. Hartford Hospital, where I took my surgical training, had a rotational program and sent one individual to Memorial for a year, and I was the fortunate one to get chosen to do that. And that, I think, further solidified my thoughts about going into surgery.
JS: Now part of that, I assume, you spent on the head and neck service.
JS: So was there a particular person on the service, per se, who you could identify as maybe a mentor for your future decision to specialize in head and neck surgery?
ES: That’s an interesting question. I was asked to stay on three separate surgical oncology services at Memorial – head and neck, GYN and gastric and mixed tumor. I elected to go on the head and neck service because I thought it was perhaps the least regimentalized in the sense that there was a broad opportunity for oncologic diseases of multiple descriptions and multiple primary sites, as opposed to for example going on the breast service and treating diseases of the breast only.
JS: When you say that you were asked to stay, that would have happened though after your –
ES: That was in my fellowship, right.
JS: That’s interesting. My father called it a senior residency. I said, “Well, wouldn’t you call it a fellowship?” But was it called a fellowship back then?
ES: It was a surgical oncology fellowship, yes.
JS: Similar to what they still do to this day.
ES: Yes. There was a time when Memorial offered a residency in surgery with obviously a major interest in surgical oncology. But that had already been deleted from the program by the time I got to Memorial. That was a three-year program. The surgical oncology fellowship was a two-year program.
JS: Once again, part of that time spent on the head and neck service.
ES: We spent at that time six months on head and neck.
JS: So there was no particular person on the head and neck service that stands out as somebody that would really –
ES: I think probably the chief of the service, Edgar Frazell was probably the most important individual. He was the one who offered me the position. He was the one who made life easy in the sense that he opened up his office for me to come into. His associate, Dr. Dan Catlan, had been ill for a year and hadn’t practiced, and when it was apparent that I was seriously considering coming on the head and neck service, the opportunity to fit into his obviously somewhat neglected and quiescent practice became available, so that the opportunity for me to step into an established but not active practice in one of the premiere offices in the city influenced my ultimate decision.
JS: Do you have any favorite stories about Dr. Frazell?
ES: I don’t know if I have any particular stories. Dr. Frazell was an interesting individual. He was a Texan. He was not given to frivolity or to wasted time. In fact, he said that if your operative procedure lasted more than four hours, you were spending too much time in the operating room and you needed to speed up your undertaking. That of course was at a time when surgical procedures were far less complex and prolonged as they are now.
JS: I guess that sort of leads us into the next question. Certainly my father had his own recollections from the 1960s on what head and neck surgery was like at the time of your fellowship and when you started your career in the mid-60s – certainly very different from what we know today in some ways.
ES: In many respects it was. I helped Hayes Martin do his last surgical procedure at Memorial Hospital. Dr. Martin was a remarkable individual who I got to know after he’d retired from active surgical practice because your father and I were involved with him in looking up some of his material and writing a couple of papers on things that were of major interest to him that he had not been able to accomplish. But he was given to a very rapid surgical procedure without a great deal of concern for blood loss, and time was of the essence because in his heyday, his major operating day I think was Wednesday, and he would do three major cases on a Wednesday afternoon after he had already seen 80 to 100 patients in the office in follow-up on Wednesday morning.
JS: And that was his only day? He must have operated on more –
ES: No, he had other days, but that was his major day.
JS: You didn’t have the complex reconstructions that were tagged on as well.
ES: No, what we did in reconstructive efforts were obviously very pedestrian and very simplistic and nothing resembling what are commonplace nowadays. The opportunity to be in the operating room for six or eight hours was almost unheard of.
JS: Is there anybody else not even necessarily from Memorial that stands out as influencing your career strongly in any particular way?
ES: I think probably the people at Memorial were the greatest influence on my career. Certainly there were people there, great names in surgical oncology, who I remember vividly in one way or another. Hayes Martin, as I say, I only got to know at the extreme end of his career. George Pack. Ted Miller. Some of the people that are no longer there, but who have been responsible for establishing the reputation of Memorial as one of the pre-eminent cancer centers in the world.
JS: So I guess the other thing, and the particular way we phrased the question is “particularly memorable experiences from your career.” Anything that stands out as a particular moment you’d want to capture I guess for posterity?
ES: Perhaps some of the most memorable experiences had nothing to do with head and neck, but rather were on the GYN service with Alexander Brunschwig, who was one of the most famous and at the same time infamous people at Memorial in the surgical department at the time. As I and my fellow residents and fellows get together every once in a while to reminisce, there are more stories about Alex Brunschwig than I think about anybody else in terms of his idiosyncrasies and his eccentricities and his character. He was more of a character and an outstanding memorable individual than most people were.
JS: I think I’ve even heard some of those stories myself.
ES: I’m sure you have.
JS: So no particular moments? I guess it’s hard to distill any particular moments over such a long career that would stand out. A particular anecdote or something?
ES: I don’t know that there’s any particular anecdote. Certainly some of the things that many people remember were the annual surgical skits that took place around the time of the Christmas holidays that the surgical house staff put together to, if you will, roast one or several members of the oncology staff for one reason or another. Those are perhaps some of the more memorable things, but I think it’s more memorable people than memorable particular incidents.
JS: I guess these next questions are more global. We touched a little bit on the first one, which is how has the practice of head and neck surgery or head and neck oncology changed over the years? Certainly your career spans a period of considerable change. Can you distill that to some of the key things that you think have evolved over the past 30 or 40 years?
ES: I think the practice of head and neck surgical oncology has become much more precise, much more complex, much more demanding in terms of training and background. When I first started, of course, the controversy between the disciplines of surgery and otolaryngology was on the minds of most people, particularly those who came from a general surgical background. As time has gone on, the demands for specialty and sub-specialty surgical training have increased, and I think in all honesty have tended to favor the otolaryngologist and his training as opposed to that in general surgery. The opportunities for a general surgeon in otolaryngology and head and neck surgery have diminished, and probably rightfully so. Certainly the science and practice of skull-based surgery was just beginning with people like Jack Lewis. Who was at NCI? The name escapes me at the moment. I’ll think of it. I should be able to think of it.
JS: That’s obviously evolved a lot.
ES: Anyway, who were just beginning skull-based surgery, which obviously has dramatically and very significantly increased in its complexity and its technical demands. I think that’s one thing. I think the interdisciplinary interactions have become increasingly important. And as Dick Jesse used to say, I think more people have accepted now than in the past to be a good head and neck surgical oncologist, you also need to have a very significant background in radiation oncology and in more recent years to an element of medical oncology if you’re going to be fully qualified to make the appropriate decisions in patient management.
JS: I guess the corollary of that question is, given all of that, what has remained the constant? What’s probably changed the least over time?
ES: I would like to think that the attention to detail and the commitment to patient care and the regimentation of training dedicated to those qualities hopefully haven’t changed much, although I suspect they have in many elements.
JS: I think that that’s a reflection of the practice of medicine in general these days. I guess we can get back to that in a minute. I guess you could jump to that. The next question is what’s the biggest current threat to head and neck surgery or head and neck oncology, and on the other hand, what’s the biggest opportunity? Maybe we’ve alluded to some of the threats already.
ES: Obviously the threat to surgical oncology is the increase in utilization of non-surgical treatment in the case of the patients particularly with advanced head and neck cancer. I think there still needs to be a role for the surgeon who at least until recently if not still is perhaps most closely related to the diagnosis and the initial evaluation of the patient with head and neck cancer, and who, perhaps if appropriately qualified in the three disciplines that we already suggested, maybe the one who should be the captain of the ship to direct patients to the appropriate sub-specialty when necessary, recognizing what the advantages and disadvantages of each are, and can appropriately discuss it from a more global point of view than can the other disciplines with the patients.
JS: Here’s another that I guess one can consider a self-serving question, but we were asking all of our interviewees what they feel has been their most valuable contribution to the field during the course of their career.
ES: I think probably the effort that I would be most grateful for having been involved in is the combination of radiation and surgery. In other words, perhaps the initial effort in multidisciplinary management of head and neck cancer. It had already been started at the time that I got to Memorial, but I had the opportunity to be involved on the ground floor for some of the pre-operative radiation studies and results, and that I think has been perhaps one of the things that I have been most interested in. The training of surgical head and neck surgical fellows I think has been another aspect of my career that I take the greatest pride in. Certainly it’s very heartwarming to see my graduates and have them come up and speak to me and speak usually warmly of their experience with us while they were there at Memorial.
JS: Or come back and interview you. I guess in terms of threats I heard that the match program for the fellowship applicants has dwindled even further.
ES: That’s what I understand, and it’s very distressing to hear that. At one time we were concerned that we were creating a program that would be over-subscribed. Now we see that the program is dramatically under-subscribed. I’m not sure of its etiology, but clearly it’s a reflection of the fact that we have not been able to attract and to appropriately employ enough young people in head and neck surgical oncology. It may be a reflection of the times. I’m not certain.
JS: My own speculation is that it’s a reflection of reimbursement for head and neck surgery, which is poor to begin with, and people not wanting to spend the extra time and training to do something that is perhaps not well-compensated for, but that’s speculation on my part.
ES: I think that’s true. And I think that was also the case when I first started in head and neck oncology in that not all people who had some training in head and neck ultimately did head and neck, for whatever reasons. And it clearly was obvious that a commitment to a dedicated head and neck oncological practice required a great deal of investment of one’s time and efforts and was not very ruminative, and that certainly has become increasingly so as time has gone on.
JS: With otolaryngology taking the lead as far as providing the trainees when you look at the field and the different sub-specialties within ENT, it’s very obvious that the least well-compensated among the various sub-specialties in ENT is head and neck surgery. So given a choice of various things to do within the field of otolaryngology, it certainly is less appealing financially.
ES: I’m sure that’s true. I’m sure another reflection is that as the other disciplines involved have become increasingly committed, certainly to a much greater degree than they used to be towards the managing of patients with head and neck cancer, there’s far greater competition for those patients and in many instances the patient may never even actually see a surgeon. Whereas when I first started, he or she almost always began by seeing a surgeon in the treatment of his or her disease.
JS: I guess perhaps appropriately the last question that we put down was whether you have any particular words of wisdom that you would like to convey to current and/or future head and neck surgeons or surgical oncologists?
ES: I can only speak from my own experience, but I obviously derived a great deal of satisfaction from my interaction with my patients and with their families in my close to 40 years of practice in head and neck oncology. And as I look back on it now, having retired four years ago, the greatest reward still is the recognition that patients have afforded me and the kindness and the interest and the thoughtfulness that they’ve extended on my behalf, and that was true during my practice and it’s also to a degree extended since I retired. I think the commitment that one makes to the care of one’s patients is an investment, and that investment pays off in direct proportion to the extent of the commitment that one makes. That can occur whether one is reimbursed or not and whether one is an otolaryngologist or a medical oncologist or radiation oncologist. The more care you take of your patients, the better the patients will care for you.
JS: I think that’s good wisdom in this day and age when there’s considerable pressure not to spend the time and to move along and to depersonalize the whole thing.
ES: As I’ve said privately and publicly, I personally believe that we are still involved in a profession and not a job.
JS: May it always be so.
ES: I hope so.
JS: Well once again thank you for your time, and we look forward to being able to see you at future society activities for some time to come.
ES: Thank you very much. I appreciate the opportunity to talk with you.