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Q: You recently switched chair positions. Why?
FEE: That's easy. Originally I thought 10 years as chair would be enough, but at 10 years there were a lot of things I hadn't done and still wanted to do. Mainly, I wanted to find more money to ensure our viability and independence in research. I finally decided 20 years was enough, and I had to coerce Richard into taking the job. He's doing a wonderful job.
GOODE: He lied. Bill told me this was a good job, and I bought into it. Seriously, we're searching for a permanent replacement now. We're shooting for December, but maybe it will take a little bit longer. As for my taking the interim job - I didn't want the job permanently, which is always a good qualification for an interim person. If you give the job to an inside candidate, outside people say, "Why bother to apply?" Secondly, I've been here a long time so I know how the system works. This is a good time for me to do this. I knew I would have burned out fairly quickly if I'd done this on a permanent basis years ago.
Q: Will you help pick your successor?
FEE: Neither one of us is actively part of the search in round one. Among other issues, we have internal candidates. We may be involved in subsequent rounds. I think the committee will do a great job.
Q: Why does someone become an otolaryngologist? Is that something you dream of aspiring to at an early point in medical school?
GOODE: No. Not unless your father or Uncle John is one or you've had a mastoid operation as a child. I liked the variety, the anatomy is fascinating and we deal with interesting themes - the ear, cancer, facial plastic, larynx, allergy. We see different age patients, and we have a mix of surgery and medical problems. I found when I was in medical school that most of the people in the field are happy.
FEE: My reasons are pretty similar, and I think if you went out and asked the residents, they'd say pretty much the same things, too. During my medical school rotations I noticed that the faculty and residents In ENT were the only group of residents and faculty who seemed generally happy. And I said, "Wow, that's really interesting. What is it about this field that makes these guys so happy?" After two weeks on the service I found that the attraction was the high variability - as Dick says, half surgery, half medicine, from pediatrics to geriatrics.
Q: Do you have an unusual cluster of programs in your division?
FEE: Not really. I'd say we're on a par with the better programs nationally. We have a mix of facial plastics, head and neck, otology, neuro-otology, pediatric otolaryngology, and we have a comprehensive research program.
Q: Is cosmetic surgery a major revenue generator?
FEE: No, not for us and I would doubt for plastic surgery either, but it is a source of support and we certainly don't want it to go away. It's probably about 10 percent of our revenue. It certainly doesn't hurt the bottom line, and overall it's important to our mission. Personally, I'm very grateful for my cosmetic surgery training. I'm a better head and neck surgeon because of it. I try to do aesthetic head and neck surgery - remove tumors with as little visual impact as possible. We try to pass this philosophy on to our residents.
Q: Are you seeking more business for your clinical service?
GOODE: I suppose if we had more personnel we could beat the drum and get more cases, but then what would we do? We have limited operating time, staff and space. Increased volume is a goal for the future.
Q: Is that goal true across your service?
GOODE: The facial plastic area is a little tougher to expand, because we're competing with excellent people, some of them we have trained and who have chosen to practice outside the facility. Also, in this area we overlap with several other subspecialists - general plastic surgeons, eye plastic surgeons, and dermatologists. And oral surgeons are moving into the facial cosmetic realm. Our training program has many benefits, but unfortunately nurturing intimacy and privacy aren't two of those benefits. But I think we can work on that, especially as the new Clinical Cancer Center opens, freeing space for us. We do great work, but without a marketing program and without a physically enticing physical plant it's hard to sell what we do as well as people who aggressively market and advertise. On the other hand, we have some premier areas, including what Jim Koch is doing in laser resurfacing. He was a fellow here and we brought him on the faculty. We can expand that and other areas if we get more space.
Q: It's your turn. With due respect to your plastic surgery colleagues, why would you advise your referring colleagues to refer to you for, say, a rhinoplasty?
GOODE: Over the years this kind of turf issue has ranged throughout medicine. Our feeling about cosmetic surgery on the face and the neck area is that "this is all we do." I don't do fannies, I don't do breasts, I don't do hands. I think because we're more focused, I think we can do a great job.
Q: Can you talk about your own non-cosmetic work?
FEE: My work is pretty focused on head and neck tumor surgery, while Dick does a wide variety of things. In the last few years, he has developed a series of procedures to correct facial paralyses. Twenty years ago, no one thought that these could be surgically corrected. But Dick has led efforts that have made enormous advances for people with Bell's palsy and other similar conditions. Put simply, he moves portions of muscles and their associated nerves and blood vessels from one site to another, and when that's not possible, he can often provide reconstruction to shore up sagging or drooping muscles.
GOODE: Reconstruction without restoring nerve function and muscle control obviously doesn't restore function, but many people benefit by at least presenting a more normal appearance. Patients are often hampered in their jobs and personal lives because of a drooping of their paralyzed face. Incidentally, Bill said some nice things about me, so it's more than fair to reciprocate: He is recognized as one - if not the - best head-and-neck cancer specialist in the world. FEE: I can always count on Dick. [laughter]
Q: Can you talk about some of the subspecialty work of your colleagues?
FEE: Well, Winston Vaughan is the first fellowship-trained endoscopic sinus surgeon in the greater Bay Area. He's a wizard with the endoscope. Dave Terris, among other areas of expertise, is outstanding in sleep apnea surgery, which has been invaluable for those patients who haven't responded to nonsurgical treatments from places such as our own Sleep Disorders Clinic. Dave has been extremely innovative in researching a variety of surgical techniques, including a procedure that prevents the tongue from falling back into the pharynx. We've already mentioned Jim Koch's work with laser peeling, and it's important to note that this work has a real role in reconstruction, as well as in cosmetic surgery.
Q: How did you choose your research areas?
GOODE: When we each started we both pretty much did everything. Bill then focused down. I didn't focus down quite as much. The university likes narrower and narrower subspecialties. I found out early on that you couldn't get funding for doing research on facial plastic surgery. But middle-ear physiology was of great interest to funding sources, and it was fun for me.
FEE: Our research is really collaborative - both within the department and throughout the medical school and beyond. We have a very active collaboration with Martin Brown, a basic researcher in radiation therapy. We've been working closely on tumor hypoxia. Martin's efforts are promising in that we can almost literally "starve" tumors, particularly important in the head in the neck. One of the most promising areas of Jim Koch's efforts in cartilage rejunvenation, which we're working on by growing cartilage filler in the laboratory. We have our own division molecular biology laboratory, where Dr. Zijie Sun is currently looking at, among other things, the etiology of nasopharyngeal carcinoma at the genetic level. We have a wound healing and biomaterials laboratory, where Dr. Koch and colleagues are looking at keloid fibroblasts, particularly aberrant fibroblasts, a cause of unwanted thick scarring. Eventually, we'd like to be able to modify wound healing so we can stimulate it in people whose wound healing ability is compromised by immunosuppression. We'd also like to be able to find a mechanism to turn off voluptuous wound healing, which can often be functionally crucial for our patients because of the potential of airway obstruction. And strangely enough, we're also looking at prostate cancer.
Q: Prostate cancer? There are a lot of bad jokes equating the region of the prostate with the areas you ordinarily study. Are you serious?
FEE: Yes, we recently recruited Dr. Zijie Sun [assistant professor of surgery] as a basic researcher from Harvard. I told him, I don't want you to give up on your prostate studies, but I want you to take the techniques you've adopted in that area and apply them to diseases of the head and neck. His agreement with us was that after the end of his second year here, he'll be spending 50 percent of his time in diseases related to the head and neck.
Q: What is the question you hope he'll answer?
FEE: Where is the genetic aberration for people with nasopharyngeal cancer? If we learn that, we can initiate novel treatments to effect a higher cure rate. Which patients do we need to operate on? Which patients do we need to irradiate? Which patients do we need to give chemotherapy to? Then we'd like to extend that knowledge to all of head and neck.
Q: How do you make these decisions now?
FEE: Sometimes in interesting ways. In 1984, I developed an operation for patients with nasopharynx cancer when they failed radiation therapy. This came about when we operated on what we thought was a benign angiofibroma and later learned it was malignant. The patient continues to do well to this day. Soon afterward Don Goffinet [currently professor of radiation oncology] called me and said, I have a patient here with recurrent nasopharynx cancer, and I'd like you to operate on her because I can't give her any more radiation safely. I said, "Don, we don't operate for nasopharynx cancer." Well you did a few months ago, and I said, "Yeah, but that was a mistake." And he said, "I want you to do the same mistake again." I did resect Don's patient in May 1984. She did well and she's free of disease now 16 years later. I've done 45 since that time.
Q: You collaborate frequently with other services?
FEE: Our most active collaboration is with radiation therapy. We collaborate on a daily basis, and we work very closely with radiation therapy and other services at our tumor board which meets a half day each week.
Q: How did the tumor board begin?
FEE: Don Goffinet was fairly new about the time I came here in 1974. I said, "I'd really appreciate seeing patients you're treating before you start so I can find where their tumor is in case they fail and we have to operate." And so we agreed in 1976 to start a multidisciplinary tumor board. I believe we were one of the first multidisciplinary tumor boards in the country. And we agreed to disagree - agreeably.
Q: What does that mean?
FEE: The way it plays out is that each person has to give a little bit - not much, because Don and I over 24 years have agreed on thousands of patients and disagreed on the management of no more than five patients.
Q: Do you have other interdepartmental collaborations?
FEE: Of course. With neurosurgery we share tumors of the midface or the lateral skull that go up into the intracranial contents. Neurosurgery works on their part from above and we work on our part from below and we meet in the middle. We manage infections of the ears and sinuses that also have intracranial spread of infection that require neurosurgical care. In general surgery, we work mainly with gastric pull-ups where we've resected the upper esophagus and the stomach is brought up into the neck to close the defect. Occasionally, we have some unusually difficult cases such as thyroid cancer or parathyroid disease, where we'll work with the general surgeons, who provide technical support. We also work collegially with our colleagues in plastic surgery.
Q: Could you describe your relationship with the California Ear Institute [CEI]?
FEE: We needed an academic otologist to replace [the late] Blair Simmons when he retired from our faculty in 1993. Under the aegis of former Dean David Korn, we arranged a working relationship with CEI. We moved our otologic research lab to CEI, which freed up about 2,500-square feet of lab space to allow for our molecular biology research laboratory here. At CEI we now have use of a 10-station temporal bone laboratory where residents can practice on cadaver bones. The CEI faculty receive clinical appointments at Stanford. Patients referred for otology procedures to faculty members, including Drs. Goode, Terris or Messner, will be treated by those faculty members, but other referrals are sent to CEI, which maintains its independence, including its practice income. But the group is an annex to the teaching program, and the doctors are outstanding teachers. As you know, teaching decreases your profitability. It slows you down. But in fact their profitability may be enhanced, because they get our referrals and carry the Stanford name.
Q: Anything you'd like to add?
FEE: Yes. The perfect job doesn't exist, but this is pretty close. It helps me maintain an attitude of optimism and enthusiasm, which I think helps us all become successful.
GOODE: I'd like to put in a plug for our residents and staff who carry a large load. Sometimes they are forgotten when awards are passed out. Incidentally, regarding awards, our program is always in the top 10 or 15 program in the U.S. News & World Report annual surveys. We're one of the smaller programs - out of nearly 90 - so it shows we're doing a lot of things right. We still want to be number one.
