Dr. Patrick C. Walsh is the Chairman Emeritus of the Brady Urological Institute and a Professor of Urology at the Johns Hopkins School of Medicine. He is recognized internationally as a pioneer in the diagnosis and treatment of prostate cancer. His life-story and career in surgery reflect presence, kindness, faith, and resolute commitment to purpose. (Music Credit: Sunshine, Simon Jomphe Lepine.)
Dr. Patrick C. Walsh is the Chairman Emeritus of the Brady Urological Institute and a Professor of Urology at the Johns Hopkins School of Medicine. He is recognized internationally as a pioneer in the diagnosis and treatment of prostate cancer. His life-story and career in surgery reflect presence, kindness, faith, and resolute commitment to purpose. (Music Credit: Sunshine, Simon Jomphe Lepine.)
My name is Phil Pierorazio and I'm a urologic oncologist, a surgeon. Like many of you, I absolutely love what I do, and I would not choose another profession. But I've struggled professional identity practice efficiency and wellness over the years. operate with Zen is a podcast designed to explore a mindful approach to surgery and to being a surgeon. By discussing these struggles and mindful solutions, I hope together we can create a community of strong and healthy surgeons enjoy. Welcome to Operate with Zen, in this episode, I have the pleasure of interviewing urology, great Patrick C. Walsh. And while this interview is a little different, we don't cover concepts of mindfulness outright, I want you to listen for the concepts that are covered throughout the discussion, you'll hear the important discussions about purpose and faith, about intention. And about being kind. You'll hear concepts of essentialism, we're really big focused on long term goals and not spreading yourself too thin. And you'll hear a lot about coincidence and divinity and a greater good, I hope you enjoy. So welcome to operate with Zen. We have the pleasure today of talking with Dr. Patrick C. Walsh, who's the University Distinguished Service Professor Emeritus of the James Buchanan Brady Neurological Institute at the Johns Hopkins Hospital. He's one of my great mentors and educators throughout my training and my life. And it's an absolute pleasure today, to be talking to Dr. Walsh. We're going to talk about a number of topics. We're going to talk about purpose, we're going to talk about mentors and mentoring. We're going to be talking about an evolution of of life and goals. So we'll start this way Dr. Ross, tell me about your early years, and how they influenced your life. So Phil,
Patrick C. Walsh:it's great being with you. So I'll introduce Phil. Phil was one of my great residents and subsequent faculty members, is the great guy, brilliant surgeon. And I've enjoyed all the years I've known you. I was lucky to be brought up in a religious family and received my education from preschool, through high school from Dominican nuns. Every day, we were reminded why we were on this earth to know love and serve God, and to share the gifts we were given with our fellow man. From the time I was a little boy, I always wanted to be a doctor. And the pathway for my future seemed very clear, and relatively uncomplicated. For these reasons. I never seem to lose my way. And when the future was unclear, all I did was ask for God's help.
Phillip Pierorazio:And so you talked about some of your early schooling beyond high school then tell us about your training and your mentorship in medicine, who are your mentors? How did they influence you?
Patrick C. Walsh:We were not wealthy. My father owned a little cigar store and we didn't have much money. But I received a full tuition scholarship to Case Western Reserve for undergraduate school, and funding from the Knight Foundation of the Akron Beacon journal to go there to medical school. in undergraduate school, I came under the influence of the professor of embryology, he was really a tough guy. If you didn't do well, in that course, you just didn't go to medical school. However, he had an expression which has stayed with me my entire life. You are not here to make friends. Rather, you are here to find the truth. And I may have overdone that many times in my life. But I have always lived that philosophy. In medical school, I worked closely with Claude Beck, an innovative cardiac surgeon and went off to Boston to spend two years in adult surgery at the Peter bend Brigham Hospital and one year of residency and pediatric surgery at the Boston Children's. This was a very exciting environment. Caddy Cata Varick renal transplants had just begun a couple of years before I arrived at the Brigham in 1964. And valvular replacement for rheumatic heart disease was in its infancy. I actually spent seven months in adult and pediatric cardiac surgery And this prepared me well for performing thoracoabdominal operations as a urologist. Although I had many mentors mentors during those years like Robert gross, one of the founders of pediatric surgery, and Joseph Murray, the Nobel Prize winning winner for transplantation. The person who most influenced my future career was Francis Moore, the mostly professor of surgery. In the fall of 1965, at age 27, I went to see doctor and bore for advice about where I should train in urology. His advice shocked me. He told me I should go to UCLA and train with Willard Goodwin spent a couple of years of research and then returned to the Brigham to be Hartwell Harrison's successor as chief of urology, and the Elliot Carr Cutler professor. I tell you this story, because I had no idea that I could ever reach such heights. But having been told by Dr. Moore that I could, I realized that I had to live up to that promise. And as a result, when I see young people who have great talent, I also tell them about what kind of future they may have, so they will realize their true potential. At UCLA I trained with Willard Goodwin, who pioneered the use of intestinal segments and reconstruction of the urinary tract, performed the first percutaneous to frost to me, and I believe was the first person ever to use prednisone for rejection in reading transplants. Joe coffin are brilliant surgeon was also there, and helped me to fine tune my surgical technique and develop expertise in renal vascular surgery. Something I continued to pursue when I first came to Hopkins. Ben get us was also there as a young faculty member and a role model. He was brilliant, charismatic, an excellent surgery, and probably the brightest urologist in our field at that time. Following residency at UCLA, the US was still involved in Vietnam, so I was required to spend the next two years at the San Diego Naval Hospital. It was there when I hit where I had my first exposure to radical retropubic prostatectomy. As a resident we only use the perineal approach, which Goodwin learned as a resident of Hopkins. While in San Diego, I was offered the position to be the chair at Hopkins, but explained that I had arranged to spend a year in Dallas, Texas with Jeanne Wilson, the scientist who discovered Dihydrotestosterone and could not come to Hopkins before 1974. They agreed to wait. That was a fantastic decision for everyone. Because during that year, we discovered the five alpha reductase Deficiency Syndrome and induced experimental BPH and dogs using androgens plus estrogens. In 1974, we arrived in Baltimore.
Phillip Pierorazio:I think one of the greatest things I don't know if I've ever heard you say this before. But how Dr. Moore gave you the inspiration and told you, you could reach heights that you didn't know you could. And I can say firsthand, you have inspired quite a few of us by passing that, passing that along. So that's a great insight. And I think for all of us as we think about mentoring young people, that's a really great insight to inspire them and tell them that they can do great things. And I thank you for that. Yeah. If I could diverge for one other moment, just when we think about mentors, what advice would you give now to young people coming up when seeking out mentors?
Patrick C. Walsh:I, I don't know the answer to I mean, the people you admire, I mean, I you know, that's what I did. I had, I had all these people I admired and I sought them out and talk to them. And, and, you know, most were receptive, maybe some weren't. But I think that's the important point. I, I'm always looking at it from the other side as as being a mentor who I seek out. But that's a very good question, Phil.
Phillip Pierorazio:So now, we're going to go a little further into your history. You're getting ready for your your first job at the Brady, tell us about that transition, what prepared you for that job, and then how things proceed from there.
Patrick C. Walsh:Okay, so with all that background in 1974, we arrived in Baltimore. So I came to Hopkins rather than the Brigham. Because I really felt that my goal in life was discovery. And that seemed to be an imperative at Hopkins, you know, a heritage of excellence. And shortly after I arrived, I learned a lot of things, but one of them was that radical prostatectomies were rarely performed even at the institution where the operation was pioneered 70 years earlier. Why All men were impotent. 25% had no urinary control, and patients felt that the treatment was worse than the disease. And urologists were frightened by the life threatening bleeding and didn't want to operate. So at that time, I wondered why these side effects occurred. And whether they could be prevented. Having been all around the country, as I've described, I had never heard anyone raise that possibility. So what I decided is that I would try to figure that out. And having had the experience in San Diego about the blood loss. At surgery, I decided I would tackle that first. I mean, it was amazing, all the different places where they wouldn't have cystectomy was done. The dorsal and the mistake was the dorsal vein was transected, immediately adjacent to the pelvic floor, and it retracted. So there was no way to stop bleeding. And it was like a fire hydrant. And no one ever said a thing. It was like it was raining outside, you know, and no one even talked about how you could stop it. So that was my first challenge. And so I, I said, well, to Bill Reiner was a resume. So we'll go over to Welsh and Xerox the anatomy of the dorsal vein. And he said, There isn't anything. Well, that turned out to be true. And we didn't know where the nerves were either. And we knew member impotent but why. And what we didn't know is that the sphincter also was not where we thought it was. So why were we so ignorant, because of using the adult cadaver using the adult cadaver, shortly after death, the abdominal contents, compress the pelvic organs into a thick pancake of tissue, and formalin desex away the tissue planes. So you, you can't find anything there. So what did I decide to do? I decided to use the operating room as an anatomy laboratory. And so in doing cystectomy, in the few radical prostatectomies, I did, I would deselect everything out. And I realized there was a common trunk over the urethra. I learned how to ligate it and transect it with very little blood loss. And shortly thereafter, in 1977, a patient came back and told me he was fully potent. So I knew from that one patient and n of one, that the nerves did not run through the prostate, everyone believe they did because everyone was impotent. Well, in this patient, I clearly took out his whole prostate. So where were the nerves? So we looked, we looked everywhere we could and and so like I referred to a little earlier, I just said to God opened my eyes. And about eight weeks later I was we went to our first meeting of the American Association of Gu surgeons, and the first night there was no social event, and my wife and I went to a restaurant downtown. And as we were approaching the table, I saw an old man standing by himself behind the maitre d who looked lonely. And for the only time in my life, I went up to a total stranger and asked him if he had anyone to have dinner with and with you. Would you like to join us? He said, That would be lovely. I said, What's your name? He said, My name is Peter donker. I said, What are you doing in town? He said, I'm attending the American Association of GE surgeons. So he was at the same meter meeting and the concierge had told him to go to the same restaurant we went to. So we had a very nice dinner. At the end of that dinner. I thought that was the end of the story. But four years later, 4000 miles away, we meet again, he was retired, and his successor invited me to spend five days lecturing, operating visiting laboratories. And on the fifth day, February 13 1981, a very easy day to remember because it was my 43rd birthday. My my host said, you know, Dr. Donkor, would like to repay the favor. He liked to take you to see the windmill museum. So I, when I saw him, I said, What are you doing these days now you're retired. So I'm working in the anatomy laboratory, and without any premonition of what I was going to see. I said, Well, I'd like to go there instead. So he takes out an infant cadaver, a dissecting microscope and his drawings. And I said, What are you doing? In the SEC, I'm just setting up the nerves to the bladder. I said, why? It's never been done before. Why? Well, I've just told the story why we were so ignorant about this. And I said, Where are the branches to the corporate cavernosa? He said, I've never looked and three hours later there they were outside the prostate. Well, fantastic day. But the next challenge was how do you find these microscopic nerves in the adult male pelvis? Well, I did not this was February, I did not do another radical prostatectomy until October. And at that, at that operation, which I have the drawings for, I saw vessels that ran in the exact location as the nerves ran in the infant cadaver. I speculated that this could be the neurovascular bundle that I could use as the macroscopic landmark. And so I now had to wait till April 26 1982, when I operated on a 53 year old professor from Cleveland, Ohio, he has cancer free, and lived a full life potent in continent. So that was a very exciting I mean experience in my life, the 40th anniversary of that operation will be coming up next April. Well, the next challenge was, was to perfect the technique, I developed a database. And you know, I've always believed that if you have been given the privilege to sail and uncharted waters, you have the responsibilities to make those charts. And so I had, you know, the preoperative findings, the interoperative, procedure, the pathology, and then as years went by changes in operative technique, and I spoke to every single patient I operated on every three months, for the first year and longer if they had not fully recovered, I operate on 4569 men. And if you do the math, that's about 20,000 telephone conversations. And what I did is I was able to operate, and every operation looked like it was a xerox copy. But what bothered me is I could operate on a 250 year old man the same day, and do what looked like the same operation. And one patient was perfect immediately, and the next one took a year or longer. So in the mid 1990s, I got an excellent video camera, and I started videotaping my cases. And then I went ahead and purposefully took 66 patients, operated on them, videotape them, and and did third party quality of life outcomes done by an independent person. And at 18 months with all of that information, I went back and reviewed all of those videos frame by frame. And I think that this is the the first time anyone at an open operation ever did that. We've done it in sports for many years. And I was able to discern about four different things that I you could not see when you operate, you're looking at the tips of your fingers. When you're watching yourself operate, you see a lot of peripheral things that are going on that begin to make sense. So my goal was to make every patient potent and continent at three months, and over 29 years, I've changed 28 I made 28 major changes. And I stopped operating in 2000 in June 2011. Having performed 4569 operations. And although I never achieved my goal, but in the patients I operated on in the last two years using all of these improvements in men who were fully potent preoperatively. At three months 50% were potent. And at 18 months 93% of three months 80% of patients were totally dry, and an 18 months 95%. And in the long run only 2% were pad that they changed more once a day. So that's the way I perfected that operation.
Phillip Pierorazio:It's really incredible. You know, I've heard versions of that story, but you learn something new and you take different things away every time you hear it. So thank you for sharing. And I also want to share, I think during my residency, I tallied them up I did right around 200 Radical prostatectomies where I was your assistant. And every single one of those was a joy. But I was also in the operating room at your last case. And it was one of the most poignant memories of my training and of my career. And I just want to share with our audience a few of the things that I've taken away with you that you may not have totally verbalized today, but you did. And one was you took the same approach to the operation every day, from the way you set up the drapes to make the incision and proceeded through the operation, obviously accounting for anatomic variants, and but what that instilled in me was that when things didn't feel right, there was something different going on right there. It created a visceral sense that something was abnormal, you had to readjust your thinking to what was different about this patient or what was different about that. That case. One of the second things was you know, you talked about talking to your patients, you know, all of the the 20,000 phone calls, and surgeons get really caught up in the operating room because that's a lot of our primary focus. But there's so much of our relationship that is with those patients and so much of the therapeutic relationship happens outside of the operating room. And you really instilled that in me and I think a lot of the trainees that you influence is that being involved in your patients lives outside of the operating room is just as empowering if not more important than what happens in those few hours with them in that special setting. And the last thing I want to point out, which I've heard you say before, but really came up poignant to me today was that when you looked at the videos and you caught in the the peripheral view, right, we're so laser focused, when we're operating, that when you were able to look at the videos, you were able to step back, and take in kind of a more global view of what was going on in the operation. And I will tell you in my surgical training, sometimes doing some really challenging cases, when I'm struggling, I purposely try and step back and take a more global view of the operation in the field, to see if there's something else I'm missing that could make that operation better. So I thank you for those insights.
Patrick C. Walsh:I really enjoyed. So everyone should know that my first assistant on all those cases was my first year resident. And as a first year resident, you would do 100 or more cases with me. And I did that because my promise to the patient was that I would do their operation. But and you can comment on this when I'm finished saying it. But having my first assistant be a first year resident, at the end of their six months doing that with only had two residents here. One person knew that operation as well as me, and that was that for that person. And so you could then go operate with everybody else. And they would say what's Walsh doing now? So it was it was a wonderful system, the patient's got the best operation. It was a time of total concentration. You would hear me share ideas about what I'm thinking? And it was it was I think it was fun for me and fun for you.
Phillip Pierorazio:It certainly was I can I can verify that. So you've kind of talked about purpose and a purpose of discovery. Tell us now has your as your career has evolved, has your purpose evolved?
Patrick C. Walsh:Okay. Over the years, I had many friends who were smarter, better educated, more talented, possibly worked harder. However, many of them failed to make a major impact in life, because they kept shifting their goals, never maintaining a long term focus. For a while it would be academics and eat, drink and be merry than physical training or some other distraction. Each time they lost focus on their long term goal. And were not able to really fulfill their potential. I was fortunate to have been able to maintain my focus all of those years, I felt my number one job as chair was training the leaders of the future. And my passion was and still is discovery, discovery and laboratory, in the clinic, or in the operating room. And although I no longer operator run a department, I am still dedicated to my patients and continue to see patients in clinic with medical students teaching them that the secret in the care of the patient is caring for the patient. And I'm still very involved with our genetic research on prostate cancer.
Phillip Pierorazio:As I've evolved a little bit I've got more into we'll call it spiritual Ness or mindfulness. And one of the concept is a concept of Dharma where talent meets purpose meets enjoyment meets service to people. And you truly embody that with your career and your contributions to our field and to our patients. And I think that's an an incredible contribution, and a shining example of what we all should aim for. I wanted to give you an opportunity if you had any questions, questions or anything else you wanted to talk about. And then I wanted to just kind of summarize some of the really salient points that I I wrote down and noted as we talk today.
Patrick C. Walsh:Well, I have a backstory to the discovery of the neurovascular bundles. The mentor I didn't talk about was my Uncle Harry. And if I get a little teary eyed when I tell this story, you'll see why. So when I was a little boy, you know, we were poor early, we didn't have a lot of things. And I had an uncle Harry, who went for a couple of years to Carnegie tech, and then came back to Akron to run his father's plumbing business. So Uncle Harry would rather be out in nature rather than underneath the sink. And when I was about eight years old, he saw that I had this same interest. So Uncle Harry and I would go on hikes every Sunday, and we would catch turtles and snakes and find arrowheads and fossils. Build transmitters. One summer, we went with a Geiger counter to Canada to hunt for uranium. And Uncle Harry would teach me big words like superheterodyne. So when I was about eight years old, Uncle Harry taught me the word, the auricular ventricular bundle of hiss. Now this was an alliteration but why he taught me that I have no idea. So after these hikes, we would go home and Ananna my mother's older sister who was a nurse would make dinner. And it gave me a chance to talk about medicine to someone. So that night I looked in her nurses dictionary. And I saw that the auricular ventricular bundle of His was the neuro muscular bundle between the Oracle and the ventricle. So from the time I was eight years old, I had this visual impression that autonomic nerves ran in association with adjacent structures. So on that day, in October 1981, when I saw those vessels, I immediately thought about Uncle Harry, and about what I learned, and, and that's what made me helped me without Association. Well, when I was a resident at UCLA, just about finishing my training, had already decided to really focus on prostate cancer. Uncle Harry died from metastatic prostate cancer with an Anna at his side. So today, if you go to Stedman medical dictionary, and you look under B for bundle, in the left hand column, you will see the atrioventricular bundle of hiss. And next to it. In the right hand column, you will see the neurovascular bundle of Walsh. Now, how did how did all that happen? I would never have made my discovery. If I had not invited an old man who I didn't know to dinner. If I hadn't met him four years later, 4000 miles away. If I had agreed to go to the windmill Museum, and not gone to the laboratory, and I had I had not known about the association of autonomic nerves with adjacent structures. So how did all of that happen? Well, if you ask Yogi Berra, Yogi Berra would say, That's too much of a coincidence to be coincidental. If you ask Einstein, Einstein would say that coincidence is God's way of remaining anonymous. And if you ask John Paul to, he would say that in divine providence, nothing is a coincidence. And that's what I believe. So I tell I tell young people, listen to your patients, if they tell you something like, you know, they're potent, and they shouldn't be listened to it, see what you can do to figure that out. And if you have any problems, just ask God for help.
Phillip Pierorazio:And if you wouldn't mind asking me asking, I know you believe strongly in service and taking care of your fellow people. And I know you spent some time outside of the hospital caring for people and and serving the community as well. Would you feel comfortable talking about some of that? Sure.
Patrick C. Walsh:So you're talking about prison ministry. So about a mile and a half from Hopkins is an enormous prison complex with about 8000 prisoners in it. And when you're driving home to the better part of Baltimore, North County, where you and I both live, you have to drive past or through actually, you drive literally through this prison complex. And on one side, there's a very foreboding wall that actually goes back to 1800. And on rainy cold nights, waiting for the traffic light to change so we can get in the freeway, you can sit there for quite a while. So there is a in the New Testament, Matthew describes a sermon that Jesus gave just before he was crucified, he talks about the end of the world and bringing everyone the Almighty will bring everyone together. And he'll put the sheep on the right and the goats on the left. And you'll turn to the Pete the sheep on the right and he will say, Welcome to eternal happiness. When I was hungry, you gave me food. When I was thirsty, you gave me drink. When I was naked, you clothed me when I had nowhere to live, you sheltered me. When I was sick, you visited when I was sick, you took care of me. And when I was in prison, you visited me. Then he turns to the, the goats on the left. And he repeats all of that by saying, I mean, when I was hungry, you didn't feed me I when I was thirsty, you you didn't give me when I was in prison, you didn't visit me. And you are you are condemned to eternal damnation. Well, I would sit in my car and think about that. And as I, as Jesus said to me, you know, why didn't you visit me today in prison? I would say, Well, you were sick, and I took care of you. But after after I stopped operating, I realized that. What was I going to say? When I faced Jesus, and he asked me when I was in prison, why didn't you visit me? I mean, I was just, you know, why don't you pull over to the curb Pat and go in. So it turned out wasn't that easy to do? But I decided that I really had to do that. And it's been a great thing to do. I've on Tuesday nights, I visit people In a Federal Penitentiary, who are awaiting trial and sentencing for federal crimes, these are people who never had a mentor, their parents died of AIDS or were killed on the streets. They never had an education. And now that they're facing long prison sentences in federal, in a federal federal system, if you're charged with a crime 99% of the time you are convicted on the first trial, and there are federal guidelines for sentencing, and there is no parole in the federal system. And so these people would request these are people who requested a religious visit. And they realize that the only person they had left was God. And it's, it's so interesting for these people to look at you. And of course, is it my belief? I'm, I'm looking at Jesus. I mean, where were you when I was in prison? And they look at me and wonder, why is this total stranger come in here to help me tonight. So it's, it's in, it's amazing. And in an hour, 30 minutes, you can make such a difference in their lives.
Phillip Pierorazio:It's incredible how you continue to impact people on big scales and little scales. It's, it's very, it's really impressive. And you continue to grow as a mentor in idle. In my eyes, I'd like to end on one, one note that's a little bit lighter, that people may not know about you, but you are a wonderful joke teller. And I will not ask you to tell any jokes.
Patrick C. Walsh:I will tell a joke, I'll tell a joke. You go ahead. Yeah, both say,
Phillip Pierorazio:tell us about the the role of jokes and how you use jokes, with your trainees, with your staff, with your patients. And, and really how that helped help with relationships.
Patrick C. Walsh:And the illness is, is that when you hear jokes, they just automatically are filed in your brain under keywords. And so when you hear a keyword, you will, it just comes out and, and opens up a folder some time where there are a bunch of jokes in there. And so it's sort of an automatic thing. Now, one of the the ways I think it helped is that, you know, when you're the boss, you've got to be sort of tough. But if you can soften things with a little bit of a joke, I always felt that that helped. But to be honest with you, I have no control over it. So I do it with patients, and I do it with everybody. So you wanted a joke the the joke that jumps to mind after again, this is a perfect example of it, because we've been talking about when I faced Jesus. So apparently St. Peter's up there one day, and all these people are lined up and he sees a guy laughing. And he thinks well, I've never seen that before. So eventually, by the time he gets up to him, he said, What are you laughing about? So this is eternity, you're going to decide where you're going to go to heaven or hell, I'll get back in line and shape up. So we watch this poor guy, and he's doing pretty well. But every time he looks down on earth, he starts to laugh. So St. Peter says What's so funny down there? He said, you know, St. Peter, down there on earth. They're still operating on me.
Phillip Pierorazio:Excellent, excellent. Well, good. So I'm just going to summarize some of the really important points I wrote down and we'll sign off. You know, I think from the beginning, I think the relationship between God and your faith, as well as seeking truth really drove you to find purpose and really helped you find that purpose throughout your life. And anytime that you wavered from that and you saw other people waver, it gave you a foundation to come back to and to reorient yourself. One of the great points I wrote down and start three times was how you told your mentees about their future and the great things they can do and how you actively inspired people you knew could great do great things, a career and a purpose in in discovery, and the heritage of excellence you talk about at Hopkins, you certainly not only participated in that but furthered it. I think you're intentional approach with patients and with the operating room is a shining example for trainees I think we see too many people now. Trying to learn by osmosis, right? Just kind of be around people, but but you can really take an active role and you take notes and you take notice of what's going on, you're present in the moment with your patients and with that operation. But at the same time, be able to step back and take the peripheral view, not only what's going on in the operating room, but what's going on in life, what's going on in the field, what's going on with others around you, being able to be laser focused, but take it all in around you, I think are all incredibly powerful lessons that I've taken
Patrick C. Walsh:from y'all thank you for this opportunity. I'm so proud of you, and congratulations on your new appointment. We're gonna miss you. But let's hope that we can keep communicating like this.
Phillip Pierorazio:Well, thank you so much. And I'd like to thank the audience for listening. And we'll talk to you again soon. Take care