University of Michigan

The University of Michigan was simply awesome. Physicians learn most of what they need to know about being a doctor after medical school and formal training. That is a fact.

While medical school gives you a platform, it’s the interaction that you get from patients and other physicians that truly gives you your expertise. While there is a lot of information to be learned about the human body, the art of medicine really has to do with your investigative skills and your ability to put together a story. That transformation began for
me at Lenox Hill, but it happened at the University of Michigan.

I owe most of my development as a physician to two people:  David Smith, who was
chairman of the division of Plastic surgery at U of M, and Riley Reese, who was
his second in command. David Smith was from Indiana and his mannerisms and
background demonstrated that. Having grown up on the Ohio-Indiana border, I got
to know quite a number of people like David. He was smart, he was charming, and
his background had afforded him an opportunity to know who he was. That’s the
advantage of growing up in small town Midwest. You get time to define yourself.
Riley was from the South, and you could hear it in every Southernism he used to explain medicine. “KISS,” he would say all the time, “Keep It Simple, Stupid.”

Michigan was a tremendous learning experience for me. My education there changed my life. David Smith and Riley Reese taught me how to think, instead of what to think. That is a gift for which I will forever be grateful.

Here’s how it worked. Weekly, we had rounds where we discussed the patients on our service and their treatment. As the chief resident on a particular service, it was your job to present the cases to the attending staff, other residents, and medical students, while
Smith and Riley (and the other attendings) asked you questions about the care of a particular patient. It was not a friendly interchange.

Smith, regardless of how much information you had on a patient, knew how to probe, how to get to the question that you couldn’t answer. You never got away without realizing there was always more to do. It was embarrassing. Remember, you have medical students present, who you’re trying to impress as a good doctor and also trying to teach. To stand
there in front of the group and have Smith dissect you was painful.

Riley Reese, in his own way was just as smart, but he functioned to put you back together after Smith had dissected you. After one of these sessions, and laughing as hard as humanly possible, he said to me, “JR, why do you let David get you so flustered? You know more about the subject than he does.” And a lot of times I believe I did. But David Smith truly knew how to think, not what to think, and that gave him an advantage.  No matter what you had to say, there was always that next question that required an answer.

Interestingly, Smith really didn’t care what you chose to do for a patient (that is within reason and as long as the patient was safe). He really didn’t care how you went about caring for them. He knew you were an excellent doctor or you simply wouldn’t be there
in the first place. What Smith cared about most was that you knew why you were doing
it?  He required that you have at least five articles written in the plastic surgery literature that explained why you made the decision you made.

I soon learned very well how to think and as a result to be even more thorough with my patients. Clearly one of the greatest accomplishments in our time has been the computer. It gives us the ability to be experts by searching for information around the globe in an
instant. I would pull up obscure articles written in Russia, Romania, or France
and have them translated to English. I would then quote that study during one
of Smith’s sessions. The other residents would look at me in amazement. The
answer, though, wasn’t that I had done any more work, and certainly that I
didn’t have any more smarts than my colleages (those guys were amazing). The
answer was that I had learned the gift from Smith, and he in fact was a genius
at it.

The University of Michigan took three plastic surgery residents per year. That meant that there were a total of six of us in a two-year program. However, the year before I arrived in Ann Arbor there had been only two. Dan, who started the program with us and had
been the selection the year before, had taken a year off to do research. This
guy was brilliant. (I comment on that because we, the plastic surgery
residents, worked much harder than most residents in heart surgery. I can’t
imagine how hard it was the previous year for the two guys ahead of us.) The
most grueling day each week was Smith’s clinic. Smith saw about 100 people that
day. When you did his clinic, you had to see them all. Therefore, you saw 45
people in the morning prior to lunch and 55 afterwards.

Smith also taught me an important key about how you treat patients. Having to see 45 patients in about three hours meant that you didn’t get to spend a lot of time with them, but you clearly had to make them feel that way. And so in my interactions with patients, I
learned to do a few things:  1) I always sit down and never stand by the door; 2) regardless of what the patient has to say or I have to say, I always wait until the patient has completely finished and I allow for that awkward pause that occurs when people are done and we’re just sitting there staring at each other; 3) I never look at my watch, and I
always look the patient in the face; and 4) finally, you never touch the
doorknob until you’re ready to leave the room. That way, no matter how much
time you spent with the patient, there was completeness. That gave the patient
the impression they had had enough time to say what they needed to say.

Managing people was Dr. Smith’s forte, and he was a master at it. The greatest recollection I have of him was sitting in his office one day when his wife called. Dr. Smith had two sons,
both in their early teens. That day Nancy had called, not really to ask for any
help, but to release some of the stress that accompanies raising two boys. You
could hear her through the phone. Her speech was pressured, going on and on,
not pausing between sentences, and certainly not pausing between paragraphs. On
and on she went without taking a breath.  After about three minutes of this, Smith calmly spoke into the phone and said, “Nancy, just tell me what you want me to do and I’ll do it.” Wham. There was complete silence at the other end of the phone. There’s not much you can say to that. You could feel her calm down. You could feel her get control.  I thought, “Wow, that’s one to keep for the ages.” If you do whatever someone else wishes (that is of course within reason), there’s not much more to add.

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